nd medicaid professional services fee schedule as of 7/1/2020 · 15756 $2,331.69 15757 $2,319.86...

Code Modifier Medicaid Fee

10004 $52.51

10005 $133.11

10006 $61.01

10007 $308.38

10008 $174.90

10009 $488.45

10010 $293.59

10021 $100.94

10030 $643.38

10035 $472.18

10036 $401.93

10040 $113.15

10060 $124.61

10061 $214.83

10080 $217.79

10081 $313.19

10120 $156.78

10121 $279.17

10140 $175.27

10160 $134.22

10180 $260.68

11000 $58.42

11001 $24.03

11004 $579.04

11005 $778.34

11006 $707.72

11008 $273.25

11010 $487.71

11011 $540.22

11012 $691.08

ND Medicaid

Professional Services Fee Schedule

as of 7/1/2020

Inclusion or exclusion of a procedure code, supply, product, or service does not imply

Medicaid coverage, reimbursement, or lack thereof.

1 of 300


ND Medicaid


as of 7/1/2020



11042 $129.79

11043 $237.38

11044 $319.10

11045 $42.15

11046 $74.69

11047 $123.87

11055 $65.08

11056 $76.54

11057 $84.30

11102 $103.53

11103 $54.72

11104 $130.15

11105 $62.49

11106 $157.89

11107 $74.32

11200 $91.33

11201 $18.86

11300 $103.90

11301 $125.72

11302 $145.31

11303 $160.11

11305 $109.08

11306 $127.57

11307 $149.01

11308 $159.37

11310 $119.80

11311 $141.99

11312 $164.17

11313 $191.53

11400 $129.79

11401 $157.89

11402 $174.90

11403 $201.15

11404 $227.77

11406 $323.17

2 of 300


ND Medicaid


as of 7/1/2020



11420 $130.89

11421 $164.54

11422 $184.51

11423 $209.65

11424 $241.08

11426 $343.14

11440 $144.58

11441 $176.74

11442 $196.34

11443 $232.58

11444 $290.26

11446 $398.97

11450 $418.20

11451 $520.25

11462 $408.21

11463 $529.49

11470 $443.71

11471 $540.22

11600 $203.37

11601 $236.28

11602 $254.76

11603 $289.89

11604 $322.43

11606 $458.50

11620 $204.48

11621 $237.38

11622 $262.90

11623 $307.64

11624 $347.57

11626 $417.09

11640 $209.28

11641 $245.52

11642 $278.43

11643 $326.50

11644 $401.93

3 of 300


ND Medicaid


as of 7/1/2020



11646 $521.36

11719 $14.42

11720 $33.65

11721 $46.59

11730 $114.26

11732 $34.39

11740 $55.46

11750 $162.32

11755 $126.46

11760 $201.15

11762 $306.16

11765 $175.64

11770 $319.10

11771 $613.43

11772 $743.95

11900 $56.57

11901 $70.99

11920 $191.90

11921 $218.16

11922 $61.38

11950 $80.98

11951 $109.45

11952 $147.16

11954 $161.95

11960 $1,000.93

11970 $624.52

11971 $497.69

11976 $148.27

11980 $96.88

11981 $105.38

11982 $119.43

11983 $147.53

12001 $92.44

12002 $112.78

12004 $131.26

4 of 300


ND Medicaid


as of 7/1/2020



12005 $173.05

12006 $204.11

12007 $232.95

12011 $112.41

12013 $117.21

12014 $142.36

12015 $171.57

12016 $217.79

12017 $153.82

12018 $173.79

12020 $302.83

12021 $175.27

12031 $260.31

12032 $312.45

12034 $333.89

12035 $396.01

12036 $440.38

12037 $498.43

12041 $260.68

12042 $309.86

12044 $383.07

12045 $417.83

12046 $499.54

12047 $547.61

12051 $280.65

12052 $314.66

12053 $367.91

12054 $386.03

12055 $499.54

12056 $586.81

12057 $622.30

13100 $352.75

13101 $414.50

13102 $123.50

13120 $367.54

5 of 300


ND Medicaid


as of 7/1/2020



13121 $444.45

13122 $134.59

13131 $402.67

13132 $492.89

13133 $178.96

13151 $438.90

13152 $519.88

13153 $194.86

13160 $810.88

14000 $641.90

14001 $815.32

14020 $714.37

14021 $887.05

14040 $777.97

14041 $951.76

14060 $789.80

14061 $1,024.60

14301 $1,105.58

14302 $221.49

14350 $707.35

15002 $359.04

15003 $73.95

15004 $411.17

15005 $123.50

15040 $268.44

15050 $601.97

15100 $882.61

15101 $193.01

15110 $818.27

15111 $114.99

15115 $815.69

15116 $169.35

15120 $870.04

15121 $216.31

15130 $737.67

6 of 300


ND Medicaid


as of 7/1/2020



15131 $100.57

15135 $894.44

15136 $99.46

15150 $707.35

15151 $119.06

15152 $155.30

15155 $818.27

15156 $159.37

15157 $177.85

15200 $856.73

15201 $150.49

15220 $791.65

15221 $139.03

15240 $955.45

15241 $186.36

15260 $1,030.15

15261 $215.94

15271 $154.19

15272 $26.62

15273 $318.36

15274 $80.61

15275 $161.95

15276 $34.76

15277 $348.68

15278 $94.66

15570 $934.01

15572 $903.32

15574 $921.81

15576 $819.38

15600 $343.51

15610 $371.98

15620 $455.17

15630 $472.92

15650 $522.47

15730 $1,554.46

7 of 300


ND Medicaid


as of 7/1/2020



15731 $1,146.99

15733 $1,063.79

15734 $1,522.66

15736 $1,244.61

15738 $1,317.08

15740 $1,027.19

15750 $934.01

15756 $2,331.69

15757 $2,319.86

15758 $2,334.28

15760 $867.82

15769 $490.67

15770 $679.98

15771 $590.13

15772 $184.88

15773 $595.68

15774 $179.33

15775 $379.00

15776 $519.51

15777 $218.90

15780 $916.63

15781 $564.25

15782 $559.44

15783 $479.95

15786 $249.96

15787 $42.15

15788 $448.15

15789 $556.12

15792 $401.56

15793 $492.89

15819 $813.10

15820 $591.24

15821 $632.29

15822 $467.74

15823 $634.13

8 of 300


ND Medicaid


as of 7/1/2020



15830 $1,194.69

15832 $937.34

15833 $893.34

15834 $910.34

15835 $953.98

15836 $762.07

15837 $888.53

15838 $657.80

15839 $904.43

15840 $1,028.30

15841 $1,819.95

15842 $2,766.90

15845 $1,040.50

15851 $106.49

15852 $46.96

15860 $109.08

15920 $633.03

15922 $808.29

15931 $702.91

15933 $874.48

15934 $956.93

15935 $1,175.46

15936 $910.71

15937 $1,058.25

15940 $709.20

15941 $931.42

15944 $926.61

15945 $1,037.17

15946 $1,653.93

15950 $618.97

15951 $911.82

15952 $931.42

15953 $1,025.71

15956 $1,184.33

15958 $1,200.97

9 of 300


ND Medicaid


as of 7/1/2020



16000 $75.06

16020 $84.67

16025 $157.15

16030 $197.82

16035 $200.41

16036 $82.46

17000 $67.30

17003 $6.29

17004 $163.43

17106 $351.64

17107 $459.24

17108 $654.47

17110 $115.73

17111 $135.70

17250 $87.63

17260 $99.46

17261 $150.49

17262 $182.29

17263 $198.19

17264 $212.24

17266 $241.82

17270 $153.45

17271 $169.35

17272 $193.38

17273 $214.83

17274 $252.91

17276 $292.48

17280 $143.47

17281 $184.14

17282 $211.13

17283 $251.44

17284 $286.19

17286 $367.54

17311 $685.90

17312 $411.91

10 of 300


ND Medicaid


as of 7/1/2020



17313 $643.01

17314 $394.16

17315 $80.24

17340 $53.61

17360 $127.57

19000 $112.78

19001 $27.73

19020 $484.38

19030 $174.90

19081 $635.24

19082 $513.96

19083 $628.59

19084 $500.28

19085 $962.48

19086 $766.88

19100 $157.15

19101 $341.66

19105 $2,853.79

19110 $498.06

19112 $470.70

19120 $510.27

19125 $562.77

19126 $160.11

19281 $254.76

19282 $180.07

19283 $282.50

19284 $215.94

19285 $476.99

19286 $407.84

19287 $813.10

19288 $647.82

19294 $164.17

19296 $4,207.85

19297 $94.29

19298 $1,037.54

11 of 300


ND Medicaid


as of 7/1/2020



19300 $562.77

19301 $658.54

19302 $904.80

19303 $961.37

19305 $1,142.55

19306 $1,213.55

19307 $1,210.22

19316 $787.58

19318 $1,118.15

19324 $546.87

19325 $662.24

19328 $511.01

19330 $647.45

19340 $1,007.59

19342 $948.06

19350 $850.07

19355 $776.12

19357 $1,541.52

19361 $1,601.79

19364 $2,803.87

19366 $1,412.85

19367 $1,812.92

19368 $2,236.30

19369 $2,076.93

19370 $705.13

19371 $805.70

19380 $795.72

19396 $295.81

20100 $606.77

20101 $491.78

20102 $528.01

20103 $594.57

20150 $1,018.68

20200 $217.79

20205 $301.72

12 of 300


ND Medicaid


as of 7/1/2020



20206 $248.11

20220 $257.72

20225 $436.31

20240 $149.75

20245 $353.86

20250 $393.79

20251 $427.07

20500 $117.58

20501 $143.10

20520 $217.79

20525 $491.04

20526 $80.24

20527 $86.52

20550 $55.83

20551 $57.31

20552 $56.94

20553 $65.45

20555 $337.59

20600 $51.40

20604 $78.39

20605 $53.25

20606 $86.52

20610 $63.23

20611 $96.51

20612 $63.23

20615 $257.35

20650 $218.90

20660 $237.01

20661 $502.13

20662 $523.21

20663 $481.42

20664 $854.51

20665 $116.10

20670 $384.18

20680 $631.55

13 of 300


ND Medicaid


as of 7/1/2020



20690 $605.29

20692 $1,140.33

20693 $453.32

20694 $438.16

20696 $1,209.48

20697 $2,136.83

20700 $85.04

20701 $63.60

20702 $141.25

20703 $101.68

20704 $147.16

20705 $121.28

20802 $2,780.21

20805 $3,307.12

20808 $3,994.87

20816 $2,082.11

20822 $1,794.07

20824 $2,085.80

20827 $1,842.50

20838 $2,819.77

20900 $420.78

20902 $285.45

20910 $478.47

20912 $485.86

20920 $400.45

20922 $604.55

20924 $516.55

20931 $108.71

20932 $723.99

20933 $665.19

20934 $723.62

20937 $166.02

20938 $180.81

20939 $69.14

20950 $270.29

14 of 300


ND Medicaid


as of 7/1/2020



20955 $2,510.66

20956 $2,674.09

20957 $2,783.17

20962 $2,695.17

20969 $2,783.17

20970 $2,887.81

20972 $2,880.41

20973 $3,041.63

20974 $80.61

20975 $177.11

20979 $54.72

20982 $4,019.27

20983 $6,000.43

20985 $147.53

21010 $775.01

21011 $373.09

21012 $342.77

21013 $544.28

21014 $530.23

21015 $717.70

21016 $1,023.86

21025 $856.36

21026 $584.22

21029 $787.95

21030 $511.38

21031 $405.62

21032 $405.99

21034 $1,331.87

21040 $515.44

21044 $884.46

21045 $1,236.10

21046 $1,087.09

21047 $1,316.71

21048 $1,101.51

21049 $1,232.40

15 of 300


ND Medicaid


as of 7/1/2020



21050 $911.45

21060 $827.89

21070 $647.08

21073 $397.12

21076 $934.75

21077 $2,312.84

21079 $1,575.54

21080 $1,801.46

21081 $1,655.41

21082 $1,534.13

21083 $1,463.50

21084 $1,674.63

21085 $725.83

21086 $1,721.22

21087 $1,721.22

21100 $692.56

21110 $862.28

21116 $205.96

21120 $693.67

21121 $706.61

21122 $789.80

21123 $910.34

21125 $2,973.59

21127 $4,237.80

21137 $769.84

21138 $939.19

21139 $1,135.90

21141 $1,387.70

21142 $1,425.79

21143 $1,481.25

21145 $1,619.54

21146 $1,690.16

21147 $1,780.75

21150 $1,681.66

21151 $1,850.27

16 of 300


ND Medicaid


as of 7/1/2020



21154 $1,990.78

21155 $2,208.19

21159 $2,645.62

21160 $2,869.32

21172 $2,029.60

21175 $2,268.47

21179 $1,558.53

21180 $1,742.30

21181 $758.74

21182 $2,171.96

21183 $2,364.60

21184 $2,544.67

21188 $1,680.92

21193 $1,289.72

21194 $1,486.80

21195 $1,428.38

21196 $1,467.94

21198 $1,140.70

21199 $1,075.26

21206 $1,189.88

21208 $1,782.60

21209 $834.54

21210 $2,070.64

21215 $4,317.29

21230 $758.37

21235 $747.28

21240 $1,112.23

21242 $1,054.55

21243 $1,695.34

21244 $1,051.96

21245 $1,255.33

21246 $890.01

21247 $1,655.41

21248 $1,063.79

21249 $1,453.15

17 of 300


ND Medicaid


as of 7/1/2020



21255 $1,420.61

21256 $1,271.23

21260 $1,423.20

21261 $2,516.20

21263 $2,328.00

21267 $1,664.65

21268 $2,084.70

21270 $1,042.72

21275 $863.02

21280 $594.94

21282 $400.45

21295 $194.12

21296 $417.09

21310 $130.52

21315 $283.23

21320 $262.16

21325 $449.63

21330 $575.34

21335 $728.79

21336 $654.84

21337 $423.37

21338 $675.18

21339 $765.40

21340 $758.74

21343 $1,097.81

21344 $1,410.63

21345 $803.48

21346 $983.19

21347 $1,039.76

21348 $1,103.36

21355 $441.86

21356 $513.96

21360 $522.84

21365 $1,125.17

21366 $1,307.09

18 of 300


ND Medicaid


as of 7/1/2020



21385 $765.77

21386 $667.78

21387 $799.05

21390 $822.34

21395 $1,035.32

21400 $208.17

21401 $534.67

21406 $594.20

21407 $661.13

21408 $924.76

21421 $699.21

21422 $660.76

21423 $785.74

21431 $724.36

21432 $738.04

21433 $1,779.65

21435 $1,439.84

21436 $2,088.39

21440 $656.32

21445 $809.40

21450 $601.97

21451 $787.58

21452 $739.52

21453 $1,046.05

21454 $529.86

21461 $2,101.70

21462 $2,247.39

21465 $869.67

21470 $1,210.22

21480 $121.28

21485 $923.66

21490 $857.84

21497 $716.96

21501 $481.79

21502 $507.68

19 of 300


ND Medicaid


as of 7/1/2020



21510 $450.74

21550 $272.14

21552 $449.26

21554 $737.30

21555 $438.53

21556 $535.78

21557 $964.33

21558 $1,353.31

21600 $559.44

21601 $1,184.33

21602 $1,598.46

21603 $1,764.12

21610 $1,164.37

21615 $613.80

21616 $707.35

21620 $509.53

21627 $545.02

21630 $1,223.53

21632 $1,206.89

21685 $1,003.15

21700 $354.23

21705 $529.49

21720 $513.96

21725 $549.83

21740 $1,024.60

21750 $678.14

21811 $592.35

21812 $722.88

21813 $981.71

21820 $149.38

21825 $545.39

21920 $265.49

21925 $478.10

21930 $502.50

21931 $473.66

20 of 300


ND Medicaid


as of 7/1/2020



21932 $667.78

21933 $743.21

21935 $1,034.58

21936 $1,420.24

22010 $956.93

22015 $945.84

22100 $855.25

22101 $867.82

22102 $825.67

22103 $139.03

22110 $1,034.58

22112 $1,095.22

22114 $1,095.22

22116 $138.29

22206 $2,425.24

22207 $2,383.46

22208 $579.04

22210 $1,772.25

22212 $1,493.82

22214 $1,497.89

22216 $359.77

22220 $1,619.91

22222 $1,696.08

22224 $1,597.35

22226 $359.40

22310 $307.64

22315 $891.49

22318 $1,596.98

22319 $1,768.55

22325 $1,440.21

22326 $1,474.96

22327 $1,497.15

22328 $275.84

22505 $132.00

22510 $1,902.04

21 of 300


ND Medicaid


as of 7/1/2020



22511 $1,884.29

22512 $893.71

22513 $6,965.87

22514 $6,937.77

22515 $3,889.48

22526 $2,336.87

22527 $1,960.09

22532 $1,777.06

22533 $1,663.91

22534 $356.82

22548 $1,898.34

22551 $1,680.18

22552 $389.72

22554 $1,243.50

22556 $1,651.34

22558 $1,528.21

22585 $323.54

22586 $1,964.89

22590 $1,549.29

22595 $1,479.40

22600 $1,274.93

22610 $1,257.92

22612 $1,581.45

22614 $385.29

22630 $1,550.03

22632 $314.29

22633 $1,834.00

22634 $488.08

22800 $1,359.60

22802 $2,105.03

22804 $2,423.76

22808 $1,824.02

22810 $2,036.63

22812 $2,233.71

22818 $2,187.12

22 of 300


ND Medicaid


as of 7/1/2020



22819 $2,516.57

22830 $816.06

22840 $748.76

22842 $751.72

22843 $803.85

22844 $978.38

22845 $715.11

22846 $743.21

22847 $814.21

22848 $357.56

22849 $1,296.00

22850 $728.05

22852 $699.95

22853 $254.39

22854 $329.45

22855 $1,099.66

22856 $1,615.84

22857 $1,794.07

22858 $503.24

22859 $329.45

22861 $2,241.47

22862 $2,239.25

22864 $2,001.50

22865 $2,185.64

22867 $971.72

22868 $239.23

22869 $459.98

22870 $127.57

22900 $567.21

22901 $671.11

22902 $468.11

22903 $442.23

22904 $1,059.36

22905 $1,336.31

23000 $593.46

23 of 300


ND Medicaid


as of 7/1/2020



23020 $701.80

23030 $448.15

23031 $418.20

23035 $691.82

23040 $729.90

23044 $574.97

23065 $229.99

23066 $584.59

23071 $424.11

23073 $702.54

23075 $515.44

23076 $548.35

23077 $1,135.53

23078 $1,447.23

23100 $512.48

23101 $464.79

23105 $647.45

23106 $508.42

23107 $671.11

23120 $596.05

23125 $721.03

23130 $624.89

23140 $563.14

23145 $706.61

23146 $632.66

23150 $677.77

23155 $808.29

23156 $689.23

23170 $572.02

23172 $577.93

23174 $773.16

23180 $674.44

23182 $670.74

23184 $750.24

23190 $583.48

24 of 300


ND Medicaid


as of 7/1/2020



23195 $760.22

23200 $1,528.21

23210 $1,793.70

23220 $1,971.55

23330 $299.13

23333 $471.44

23334 $1,083.76

23335 $1,289.72

23350 $159.00

23395 $1,302.66

23397 $1,157.34

23400 $986.14

23405 $631.55

23406 $783.52

23410 $833.43

23412 $865.60

23415 $709.20

23420 $986.88

23430 $757.63

23440 $767.99

23450 $960.63

23455 $1,009.07

23460 $1,104.84

23462 $1,083.39

23465 $1,133.68

23466 $1,127.76

23470 $1,218.35

23472 $1,471.64

23473 $1,640.25

23474 $1,771.88

23480 $832.70

23485 $970.61

23490 $874.11

23491 $1,029.78

23500 $225.55

25 of 300


ND Medicaid


as of 7/1/2020



23505 $364.95

23515 $732.12

23520 $242.56

23525 $400.08

23530 $583.85

23532 $635.61

23540 $237.75

23545 $351.64

23550 $583.85

23552 $664.82

23570 $238.49

23575 $415.24

23585 $993.91

23600 $338.70

23605 $478.47

23615 $897.40

23616 $1,254.59

23620 $275.84

23625 $389.36

23630 $793.13

23650 $326.50

23655 $413.02

23660 $594.94

23665 $438.90

23670 $887.79

23675 $564.25

23680 $943.99

23700 $198.93

23800 $1,040.87

23802 $1,299.70

23900 $1,403.97

23920 $1,139.22

23921 $477.73

23930 $367.54

23931 $300.61

26 of 300


ND Medicaid


as of 7/1/2020



23935 $521.36

24000 $487.34

24006 $724.73

24065 $268.81

24066 $638.94

24071 $410.06

24073 $702.91

24075 $533.56

24076 $551.68

24077 $1,049.00

24079 $1,334.83

24100 $426.33

24101 $511.75

24102 $628.22

24105 $362.36

24110 $597.90

24115 $749.13

24116 $873.37

24120 $542.43

24125 $631.92

24126 $660.02

24130 $520.25

24134 $759.11

24136 $642.27

24138 $693.30

24140 $715.11

24145 $603.45

24147 $637.09

24149 $1,195.80

24150 $1,568.51

24152 $1,363.67

24155 $864.49

24160 $1,277.14

24164 $734.71

24200 $223.33

27 of 300


ND Medicaid


as of 7/1/2020



24201 $563.51

24220 $186.73

24300 $438.90

24301 $762.07

24305 $591.24

24310 $481.06

24320 $792.76

24330 $729.16

24331 $797.94

24332 $624.15

24340 $625.63

24341 $759.48

24342 $789.06

24343 $722.88

24344 $1,113.34

24345 $716.22

24346 $1,117.04

24357 $429.29

24358 $537.26

24359 $673.70

24360 $914.41

24361 $1,021.64

24362 $1,074.89

24363 $1,473.86

24365 $650.40

24366 $694.41

24370 $1,566.29

24371 $1,805.53

24400 $836.76

24410 $1,072.30

24420 $1,044.57

24430 $1,071.56

24435 $1,092.27

24470 $682.57

24495 $834.17

28 of 300


ND Medicaid


as of 7/1/2020



24498 $879.28

24500 $367.91

24505 $510.27

24515 $893.34

24516 $871.89

24530 $389.72

24535 $629.70

24538 $776.86

24545 $943.62

24546 $1,053.81

24560 $337.96

24565 $549.46

24566 $731.38

24575 $745.80

24576 $355.71

24577 $564.99

24579 $846.01

24582 $826.04

24586 $1,103.36

24587 $1,102.99

24600 $377.89

24605 $483.64

24615 $725.83

24620 $564.62

24635 $686.27

24640 $105.01

24650 $269.18

24655 $451.84

24665 $667.78

24666 $746.17

24670 $299.13

24675 $469.59

24685 $665.93

24800 $844.16

24802 $1,016.46

29 of 300


ND Medicaid


as of 7/1/2020



24900 $749.87

24920 $744.32

24925 $577.19

24930 $785.74

24931 $944.73

24935 $1,205.78

25000 $348.31

25001 $352.75

25020 $658.17

25023 $1,225.01

25024 $795.35

25025 $1,220.20

25028 $611.21

25031 $358.67

25035 $594.57

25040 $572.02

25065 $267.34

25066 $365.69

25071 $429.29

25073 $543.54

25075 $521.73

25076 $527.64

25077 $898.88

25078 $1,173.24

25085 $458.50

25100 $354.60

25101 $413.02

25105 $495.85

25107 $628.59

25109 $548.72

25110 $349.42

25111 $329.45

25112 $395.64

25115 $772.05

25116 $614.17

30 of 300


ND Medicaid


as of 7/1/2020



25118 $390.09

25119 $507.68

25120 $511.38

25125 $603.81

25126 $608.25

25130 $459.24

25135 $569.06

25136 $505.09

25145 $528.75

25150 $576.45

25151 $594.94

25170 $1,490.86

25210 $501.39

25215 $630.81

25230 $441.86

25240 $438.53

25246 $191.90

25248 $422.63

25250 $541.70

25251 $731.01

25259 $437.05

25260 $644.86

25263 $641.90

25265 $763.92

25270 $503.24

25272 $567.95

25274 $678.88

25275 $685.53

25280 $577.93

25290 $445.56

25295 $537.26

25300 $698.10

25301 $655.95

25310 $632.66

25312 $732.12

31 of 300


ND Medicaid


as of 7/1/2020



25315 $782.04

25316 $928.46

25320 $1,004.26

25332 $857.84

25335 $957.67

25337 $904.06

25350 $688.49

25355 $776.86

25360 $666.67

25365 $929.20

25370 $1,024.23

25375 $967.66

25390 $783.89

25391 $1,010.55

25392 $1,028.30

25393 $1,144.77

25394 $796.46

25400 $817.17

25405 $1,054.55

25415 $982.08

25420 $1,182.12

25425 $977.27

25426 $1,138.48

25430 $742.47

25431 $800.53

25440 $782.41

25441 $951.02

25442 $823.45

25443 $795.72

25444 $840.46

25445 $735.08

25446 $1,192.47

25447 $845.27

25449 $1,052.33

25450 $627.11

32 of 300


ND Medicaid


as of 7/1/2020



25455 $739.89

25490 $730.27

25491 $750.61

25492 $918.85

25500 $285.82

25505 $515.81

25515 $681.46

25520 $584.96

25525 $802.37

25526 $969.51

25530 $269.92

25535 $501.76

25545 $634.87

25560 $292.11

25565 $527.64

25574 $685.90

25575 $916.63

25600 $341.66

25605 $552.42

25606 $675.92

25607 $749.50

25608 $839.72

25609 $1,067.49

25622 $313.92

25624 $495.85

25628 $733.60

25630 $313.55

25635 $471.81

25645 $580.15

25650 $334.26

25651 $498.80

25652 $634.13

25660 $423.37

25670 $618.61

25671 $542.07

33 of 300


ND Medicaid


as of 7/1/2020



25675 $452.58

25676 $643.38

25680 $535.04

25685 $746.91

25690 $495.85

25695 $644.49

25800 $745.80

25805 $859.32

25810 $882.98

25820 $646.34

25825 $792.76

25830 $1,002.78

25900 $723.25

25905 $712.52

25907 $624.15

25909 $696.25

25915 $1,183.60

25920 $726.94

25922 $641.16

25924 $709.57

25927 $853.03

25929 $607.51

25931 $787.21

26010 $313.55

26011 $453.32

26020 $566.47

26025 $430.03

26030 $501.02

26034 $557.96

26035 $872.26

26037 $576.82

26040 $321.32

26045 $479.95

26055 $566.84

26060 $265.12

34 of 300


ND Medicaid


as of 7/1/2020



26070 $329.08

26075 $343.51

26080 $403.04

26100 $344.61

26105 $346.83

26110 $330.93

26111 $424.48

26113 $558.70

26115 $550.20

26116 $536.52

26117 $756.89

26118 $1,070.45

26121 $610.47

26123 $851.92

26125 $275.47

26130 $474.77

26135 $564.62

26140 $517.29

26145 $525.43

26160 $592.35

26170 $416.72

26180 $457.76

26185 $562.77

26200 $461.09

26205 $614.54

26210 $454.80

26215 $574.97

26230 $510.64

26235 $503.24

26236 $450.74

26250 $1,081.17

26260 $811.25

26262 $641.53

26320 $356.08

26340 $352.75

35 of 300


ND Medicaid


as of 7/1/2020



26341 $109.82

26350 $747.65

26352 $835.28

26356 $812.73

26357 $905.91

26358 $1,000.93

26370 $787.95

26372 $917.37

26373 $881.87

26390 $869.30

26392 $1,005.00

26410 $596.05

26412 $708.09

26415 $847.12

26416 $917.74

26418 $614.17

26420 $740.63

26426 $512.85

26428 $790.54

26432 $529.49

26433 $561.29

26434 $682.57

26437 $656.32

26440 $650.03

26442 $994.28

26445 $606.40

26449 $708.83

26450 $439.64

26455 $436.31

26460 $426.33

26471 $648.93

26474 $636.35

26476 $628.22

26477 $614.17

26478 $654.84

36 of 300


ND Medicaid


as of 7/1/2020



26479 $661.50

26480 $786.48

26483 $875.59

26485 $839.72

26489 $967.66

26490 $829.00

26492 $918.48

26494 $832.33

26496 $889.64

26497 $898.14

26498 $1,176.57

26499 $863.02

26500 $654.47

26502 $743.95

26508 $666.67

26510 $633.40

26516 $736.56

26517 $857.84

26518 $868.93

26520 $682.20

26525 $683.68

26530 $550.20

26531 $640.79

26535 $444.08

26536 $748.02

26540 $691.82

26541 $833.06

26542 $713.26

26545 $741.36

26546 $1,033.10

26548 $793.87

26550 $1,672.05

26551 $3,335.96

26553 $3,314.14

26554 $3,861.38

37 of 300


ND Medicaid


as of 7/1/2020



26555 $1,400.27

26556 $3,443.93

26560 $623.04

26561 $976.90

26562 $1,374.76

26565 $710.31

26567 $714.74

26568 $932.90

26580 $1,544.48

26587 $1,056.40

26590 $1,437.25

26591 $470.70

26593 $634.50

26596 $797.57

26600 $305.05

26605 $334.26

26607 $495.85

26608 $490.67

26615 $587.55

26641 $391.57

26645 $440.75

26650 $490.30

26665 $638.57

26670 $351.27

26675 $469.59

26676 $517.66

26685 $587.55

26686 $634.50

26700 $339.07

26705 $432.25

26706 $451.84

26715 $584.96

26720 $203.37

26725 $348.31

26727 $482.90

38 of 300


ND Medicaid


as of 7/1/2020



26735 $607.14

26740 $236.65

26742 $381.22

26746 $756.89

26750 $190.06

26755 $325.76

26756 $432.62

26765 $513.22

26770 $287.30

26775 $395.27

26776 $457.76

26785 $557.96

26820 $820.49

26841 $760.96

26842 $816.06

26843 $771.32

26844 $851.92

26850 $725.83

26852 $828.63

26860 $598.64

26861 $104.27

26862 $758.37

26863 $229.99

26910 $753.94

26951 $686.27

26952 $677.03

26990 $667.04

26991 $729.16

26992 $1,004.26

27000 $417.83

27001 $550.57

27003 $607.51

27005 $735.45

27006 $734.34

27025 $931.42

39 of 300


ND Medicaid


as of 7/1/2020



27027 $908.50

27030 $951.02

27033 $986.88

27035 $1,204.67

27036 $1,026.82

27040 $357.19

27041 $709.57

27043 $471.81

27045 $746.54

27047 $494.00

27048 $615.65

27049 $1,341.48

27050 $410.43

27052 $587.92

27054 $698.10

27057 $1,026.45

27059 $1,830.67

27060 $473.29

27062 $462.57

27065 $530.23

27066 $823.45

27067 $1,049.37

27070 $892.97

27071 $962.11

27075 $2,115.39

27076 $2,558.36

27077 $2,853.79

27078 $2,085.07

27080 $516.92

27086 $317.25

27087 $623.41

27090 $843.79

27091 $1,615.47

27093 $227.40

27095 $304.68

40 of 300


ND Medicaid


as of 7/1/2020



27096 $167.87

27097 $693.30

27098 $705.87

27100 $840.83

27105 $881.50

27110 $984.30

27111 $914.78

27120 $1,315.97

27122 $1,116.30

27125 $1,147.73

27130 $1,371.43

27132 $1,694.97

27134 $1,934.57

27137 $1,488.65

27138 $1,547.07

27140 $907.76

27146 $1,294.15

27147 $1,484.21

27151 $1,605.12

27156 $1,730.10

27158 $1,418.39

27161 $1,236.47

27165 $1,391.77

27170 $1,189.51

27175 $675.92

27176 $933.64

27177 $1,129.61

27178 $933.64

27179 $991.69

27181 $1,135.90

27185 $729.16

27187 $1,009.81

27197 $130.52

27198 $311.71

27200 $189.69

41 of 300


ND Medicaid


as of 7/1/2020



27202 $538.00

27215 $629.33

27216 $932.53

27217 $875.22

27218 $1,205.78

27220 $438.16

27222 $987.99

27226 $1,070.08

27227 $1,674.26

27228 $1,900.56

27230 $492.15

27232 $755.05

27235 $921.07

27236 $1,210.96

27238 $473.29

27240 $966.55

27244 $1,246.08

27245 $1,244.98

27246 $396.01

27248 $756.89

27250 $182.29

27252 $765.40

27253 $954.72

27254 $1,289.35

27256 $307.64

27257 $366.06

27258 $1,125.91

27259 $1,566.29

27265 $411.17

27266 $592.35

27267 $445.56

27268 $550.57

27269 $1,259.77

27275 $186.36

27279 $875.22

42 of 300


ND Medicaid


as of 7/1/2020



27280 $1,349.99

27282 $870.41

27284 $1,629.52

27286 $1,667.61

27290 $1,645.05

27295 $1,270.86

27301 $692.19

27303 $651.88

27305 $489.93

27306 $355.34

27307 $488.82

27310 $743.21

27323 $285.82

27324 $409.69

27325 $571.28

27326 $528.01

27327 $499.54

27328 $631.18

27329 $1,050.11

27330 $420.41

27331 $483.64

27332 $654.84

27333 $597.16

27334 $696.25

27335 $777.23

27337 $422.63

27339 $761.70

27340 $379.37

27345 $492.89

27347 $536.89

27350 $664.09

27355 $615.28

27356 $750.98

27357 $829.00

27358 $279.17

43 of 300


ND Medicaid


as of 7/1/2020



27360 $893.71

27364 $1,574.80

27365 $2,084.33

27369 $163.80

27372 $618.24

27380 $620.82

27381 $823.82

27385 $602.71

27386 $860.80

27390 $457.02

27391 $575.34

27392 $723.99

27393 $518.40

27394 $665.19

27395 $893.34

27396 $627.11

27397 $928.46

27400 $706.24

27403 $654.10

27405 $687.38

27407 $807.55

27409 $980.60

27412 $1,670.94

27415 $1,391.40

27416 $993.91

27418 $842.68

27420 $756.16

27422 $756.52

27424 $759.85

27425 $459.24

27427 $723.62

27428 $1,131.83

27429 $1,273.08

27430 $753.94

27435 $822.34

44 of 300


ND Medicaid


as of 7/1/2020



27437 $670.00

27438 $854.14

27440 $810.14

27441 $836.39

27442 $885.20

27443 $825.30

27445 $1,271.23

27446 $1,172.87

27447 $1,369.95

27448 $833.80

27450 $1,030.15

27454 $1,312.64

27455 $966.55

27457 $975.05

27465 $1,266.79

27466 $1,200.23

27468 $1,359.23

27470 $1,194.32

27472 $1,280.84

27475 $673.33

27477 $744.69

27479 $932.16

27485 $681.83

27486 $1,425.05

27487 $1,779.28

27488 $1,217.24

27495 $1,143.29

27496 $555.75

27497 $590.87

27498 $665.93

27499 $712.15

27500 $530.97

27501 $515.07

27502 $768.73

27503 $812.73

45 of 300


ND Medicaid


as of 7/1/2020



27506 $1,355.53

27507 $983.56

27508 $535.41

27509 $674.44

27510 $689.97

27511 $1,011.66

27513 $1,255.33

27514 $980.60

27516 $523.95

27517 $698.47

27519 $903.69

27520 $331.30

27524 $765.03

27530 $312.08

27532 $628.59

27535 $909.97

27536 $1,204.30

27538 $488.82

27540 $823.08

27550 $533.93

27552 $640.05

27556 $889.27

27557 $1,060.47

27558 $1,207.63

27560 $381.96

27562 $495.48

27566 $906.28

27570 $153.82

27580 $1,480.88

27590 $792.02

27591 $978.75

27592 $676.66

27594 $516.18

27596 $716.59

27598 $713.63

46 of 300


ND Medicaid


as of 7/1/2020



27600 $409.32

27601 $454.06

27602 $484.75

27603 $548.35

27604 $492.15

27605 $357.93

27606 $283.23

27607 $617.87

27610 $661.87

27612 $572.76

27613 $261.79

27614 $597.90

27615 $1,036.06

27616 $1,283.43

27618 $486.60

27619 $472.18

27620 $459.61

27625 $591.24

27626 $620.08

27630 $571.28

27632 $418.20

27634 $691.82

27635 $593.83

27637 $762.07

27638 $779.45

27640 $846.01

27641 $675.55

27645 $1,793.70

27646 $1,558.16

27647 $1,054.92

27648 $209.28

27650 $673.70

27652 $684.05

27654 $731.01

27656 $657.43

47 of 300


ND Medicaid


as of 7/1/2020



27658 $379.74

27659 $483.64

27664 $370.13

27665 $425.59

27675 $504.35

27676 $612.32

27680 $434.84

27681 $528.75

27685 $686.27

27686 $553.53

27687 $466.63

27690 $656.32

27691 $760.96

27692 $105.38

27695 $486.97

27696 $573.49

27698 $652.99

27700 $630.07

27702 $980.97

27703 $1,134.79

27704 $585.33

27705 $771.32

27707 $408.58

27709 $1,183.23

27712 $1,117.41

27715 $1,086.35

27720 $889.64

27722 $906.28

27724 $1,275.30

27725 $1,232.77

27726 $972.46

27727 $1,052.33

27730 $597.16

27732 $458.87

27734 $667.41

48 of 300


ND Medicaid


as of 7/1/2020



27740 $719.18

27742 $789.80

27745 $772.79

27750 $354.60

27752 $546.50

27756 $585.70

27758 $908.13

27759 $1,012.77

27760 $342.77

27762 $488.82

27766 $616.39

27767 $295.44

27768 $452.21

27769 $741.36

27780 $315.40

27781 $442.60

27784 $723.99

27786 $322.80

27788 $434.84

27792 $659.65

27808 $343.14

27810 $478.84

27814 $780.56

27816 $335.37

27818 $496.58

27822 $884.09

27823 $997.98

27824 $325.39

27825 $557.23

27826 $869.67

27827 $1,131.09

27828 $1,341.85

27829 $716.22

27830 $395.64

27831 $412.28

49 of 300


ND Medicaid


as of 7/1/2020



27832 $768.73

27840 $383.44

27842 $502.13

27846 $727.68

27848 $813.84

27860 $174.16

27870 $1,040.13

27871 $701.43

27880 $907.76

27881 $862.65

27882 $596.79

27884 $575.71

27886 $658.91

27888 $662.98

27889 $642.27

27892 $557.60

27893 $621.56

27894 $850.07

28001 $292.85

28002 $461.09

28003 $728.42

28005 $598.27

28008 $454.06

28010 $242.19

28011 $328.35

28020 $560.92

28022 $509.90

28024 $478.84

28035 $549.83

28039 $516.55

28041 $467.74

28043 $411.54

28045 $509.90

28046 $739.15

28047 $1,063.79

50 of 300


ND Medicaid


as of 7/1/2020



28050 $443.71

28052 $466.26

28054 $392.68

28055 $400.45

28060 $546.50

28062 $609.36

28070 $552.79

28072 $510.27

28080 $552.05

28086 $560.18

28088 $453.69

28090 $489.56

28092 $444.08

28100 $636.35

28102 $618.61

28103 $405.99

28104 $552.79

28106 $445.56

28107 $537.26

28108 $460.35

28110 $485.86

28111 $510.27

28112 $510.64

28113 $614.91

28114 $1,097.81

28116 $793.87

28118 $625.26

28119 $548.35

28120 $704.02

28122 $621.56

28124 $501.76

28126 $411.91

28130 $649.30

28140 $610.47

28150 $441.12

51 of 300


ND Medicaid


as of 7/1/2020



28153 $433.73

28160 $435.94

28171 $1,125.17

28173 $765.03

28175 $492.52

28190 $264.75

28192 $489.93

28193 $554.64

28200 $516.55

28202 $631.92

28208 $503.98

28210 $614.91

28220 $472.55

28222 $543.17

28225 $437.79

28226 $636.72

28230 $456.65

28232 $404.52

28234 $430.03

28238 $694.04

28240 $469.59

28250 $604.55

28260 $727.31

28261 $1,231.66

28262 $1,436.14

28264 $1,038.28

28270 $515.81

28272 $410.06

28280 $537.63

28285 $561.66

28286 $469.22

28288 $637.46

28289 $746.54

28291 $764.29

28292 $758.74

52 of 300


ND Medicaid


as of 7/1/2020



28295 $1,036.80

28296 $953.61

28297 $1,098.92

28298 $882.61

28299 $1,057.88

28300 $665.93

28302 $727.31

28304 $849.33

28305 $688.49

28306 $632.29

28307 $648.93

28308 $595.68

28309 $904.43

28310 $572.39

28312 $526.54

28313 $547.61

28315 $504.35

28320 $628.22

28322 $810.88

28340 $602.34

28341 $697.73

28344 $446.67

28345 $545.02

28360 $1,109.64

28400 $255.13

28405 $398.97

28406 $553.90

28415 $1,143.66

28420 $1,305.99

28430 $246.63

28435 $373.83

28436 $479.21

28445 $1,057.51

28446 $1,240.17

28450 $219.27

53 of 300


ND Medicaid


as of 7/1/2020



28455 $298.39

28456 $349.42

28465 $648.56

28470 $225.92

28475 $265.49

28476 $379.74

28485 $570.17

28490 $147.53

28495 $184.88

28496 $472.55

28505 $689.97

28510 $125.72

28515 $169.35

28525 $597.53

28530 $119.80

28531 $355.71

28540 $202.63

28545 $310.60

28546 $606.77

28555 $882.61

28570 $236.28

28575 $380.48

28576 $394.90

28585 $899.25

28600 $223.70

28605 $343.51

28606 $397.86

28615 $833.43

28630 $160.84

28635 $181.92

28636 $324.28

28645 $684.05

28660 $122.02

28665 $159.00

28666 $173.05

54 of 300


ND Medicaid


as of 7/1/2020



28675 $594.94

28705 $1,255.33

28715 $959.89

28725 $796.46

28730 $753.20

28735 $795.35

28737 $709.94

28740 $871.15

28750 $828.26

28755 $533.19

28760 $814.58

28800 $548.72

28805 $738.41

28810 $436.68

28820 $581.63

28825 $557.23

28890 $333.89

29000 $342.77

29010 $274.36

29015 $294.70

29035 $256.98

29040 $293.59

29044 $288.04

29046 $315.40

29049 $99.83

29055 $223.33

29058 $124.61

29065 $96.88

29075 $87.26

29085 $96.14

29086 $80.24

29105 $82.83

29125 $65.45

29126 $78.76

29130 $41.78

55 of 300


ND Medicaid


as of 7/1/2020



29131 $52.88

29200 $34.02

29240 $32.17

29260 $31.06

29280 $31.43

29305 $248.48

29325 $275.10

29345 $137.18

29355 $143.84

29358 $161.58

29365 $123.87

29405 $81.35

29425 $78.02

29435 $116.10

29440 $44.37

29445 $133.48

29450 $147.90

29505 $86.89

29515 $72.10

29520 $36.61

29530 $31.80

29540 $29.21

29550 $19.60

29580 $65.08

29581 $93.55

29584 $87.26

29700 $63.97

29705 $65.08

29710 $123.50

29720 $85.41

29730 $62.86

29740 $99.83

29750 $108.34

29800 $537.63

29804 $641.16

56 of 300


ND Medicaid


as of 7/1/2020



29805 $478.84

29806 $1,073.78

29807 $1,050.48

29819 $596.79

29820 $546.13

29821 $603.45

29822 $587.18

29823 $638.57

29824 $687.01

29825 $596.79

29826 $176.00

29827 $1,086.35

29828 $932.53

29830 $464.42

29834 $501.39

29835 $517.66

29836 $594.94

29837 $537.26

29838 $603.45

29840 $460.72

29843 $494.00

29844 $510.27

29845 $594.94

29846 $533.19

29847 $552.79

29848 $520.99

29850 $633.77

29851 $943.62

29855 $794.98

29856 $1,004.26

29860 $677.03

29861 $733.23

29862 $826.41

29863 $828.63

29866 $1,066.01

57 of 300


ND Medicaid


as of 7/1/2020



29867 $1,296.00

29868 $1,692.75

29870 $588.65

29871 $522.84

29873 $540.22

29874 $546.87

29875 $505.46

29876 $664.46

29877 $631.55

29879 $672.59

29880 $571.65

29881 $550.94

29882 $703.65

29883 $854.14

29884 $629.33

29885 $766.51

29886 $646.34

29887 $763.18

29888 $995.39

29889 $1,240.17

29891 $685.90

29892 $670.74

29893 $667.04

29894 $510.64

29895 $477.73

29897 $511.38

29898 $576.82

29899 $1,048.26

29900 $508.42

29901 $546.50

29902 $579.78

29904 $647.45

29905 $538.37

29906 $679.25

29907 $889.64

58 of 300


ND Medicaid


as of 7/1/2020



29914 $1,009.81

29915 $1,038.65

29916 $1,039.39

30000 $261.42

30020 $264.01

30100 $146.79

30110 $247.74

30115 $458.13

30117 $970.24

30118 $791.28

30120 $525.80

30124 $299.50

30125 $645.23

30130 $408.21

30140 $290.63

30150 $803.85

30160 $810.14

30200 $115.36

30210 $153.82

30220 $317.25

30300 $197.08

30310 $209.28

30320 $478.84

30400 $1,233.51

30410 $1,426.90

30420 $1,445.75

30430 $1,071.93

30435 $1,348.88

30450 $1,775.95

30460 $848.59

30462 $1,630.63

30465 $1,022.75

30520 $663.72

30540 $727.68

30545 $992.06

59 of 300


ND Medicaid


as of 7/1/2020



30560 $305.05

30580 $646.34

30600 $609.73

30620 $658.54

30630 $662.98

30801 $225.55

30802 $285.45

30901 $147.90

30903 $234.80

30905 $349.79

30906 $364.21

30915 $600.49

30920 $870.41

30930 $121.28

31000 $188.21

31002 $195.60

31020 $492.15

31030 $670.37

31032 $595.31

31040 $804.22

31050 $510.27

31051 $683.68

31070 $466.26

31075 $820.12

31080 $1,079.69

31081 $1,159.93

31084 $1,201.34

31085 $1,239.80

31086 $1,169.54

31087 $1,118.15

31090 $1,093.74

31200 $621.56

31201 $789.43

31205 $956.56

31225 $1,859.88

60 of 300


ND Medicaid


as of 7/1/2020



31230 $2,060.66

31231 $200.04

31233 $269.92

31235 $308.01

31237 $259.94

31238 $255.50

31239 $626.37

31240 $160.47

31241 $451.47

31253 $508.79

31254 $432.25

31255 $329.08

31256 $183.03

31257 $453.32

31259 $479.58

31267 $269.55

31276 $384.18

31287 $204.48

31288 $237.38

31290 $1,159.19

31291 $1,230.92

31292 $1,009.81

31293 $1,090.42

31294 $1,247.56

31295 $1,972.66

31296 $1,998.54

31297 $1,957.50

31298 $3,763.77

31300 $1,294.52

31360 $2,110.95

31365 $2,607.16

31367 $2,235.93

31368 $2,479.60

31370 $2,103.55

31375 $1,997.06

61 of 300


ND Medicaid


as of 7/1/2020



31380 $1,969.33

31382 $2,158.65

31390 $2,887.81

31395 $3,046.07

31400 $1,005.74

31420 $838.98

31500 $144.95

31502 $35.50

31505 $89.85

31510 $218.90

31511 $217.42

31512 $216.31

31513 $132.37

31515 $213.72

31520 $157.52

31525 $257.35

31526 $158.26

31527 $196.71

31528 $145.31

31529 $162.69

31530 $201.52

31531 $214.09

31535 $190.80

31536 $212.61

31540 $244.04

31541 $266.23

31545 $365.69

31546 $555.38

31551 $1,555.94

31552 $1,501.22

31553 $1,712.35

31554 $1,712.72

31560 $316.14

31561 $344.98

31570 $347.20

62 of 300


ND Medicaid


as of 7/1/2020



31571 $251.44

31572 $537.63

31573 $283.23

31574 $1,049.00

31575 $126.83

31576 $277.32

31577 $287.30

31578 $312.08

31579 $197.08

31580 $1,303.40

31584 $1,439.10

31587 $1,211.70

31590 $902.21

31591 $1,101.88

31592 $1,749.69

31600 $309.49

31601 $457.02

31603 $324.65

31605 $335.00

31610 $975.05

31611 $543.17

31612 $88.74

31613 $446.30

31614 $743.21

31615 $175.64

31622 $249.59

31623 $279.17

31624 $260.31

31625 $357.19

31626 $872.63

31627 $1,339.26

31628 $379.37

31629 $469.59

31630 $203.37

31631 $232.58

63 of 300


ND Medicaid


as of 7/1/2020



31632 $65.45

31633 $81.72

31634 $1,802.57

31635 $292.48

31636 $225.18

31637 $79.50

31638 $255.13

31640 $257.35

31641 $262.90

31643 $181.18

31645 $273.25

31646 $146.42

31647 $215.94

31648 $204.85

31649 $69.88

31651 $76.54

31652 $1,148.47

31653 $1,197.28

31654 $126.46

31660 $201.89

31661 $214.09

31717 $283.97

31720 $56.57

31725 $80.98

31730 $1,241.28

31750 $1,402.12

31755 $1,773.36

31760 $1,363.67

31766 $1,761.90

31770 $1,318.93

31775 $1,386.96

31780 $1,213.55

31781 $1,373.28

31785 $1,091.90

31786 $1,429.85

64 of 300


ND Medicaid


as of 7/1/2020



31800 $731.38

31805 $812.73

31820 $446.67

31825 $615.28

31830 $475.88

32035 $727.31

32036 $778.71

32096 $796.83

32097 $797.57

32098 $756.16

32100 $805.70

32110 $1,460.17

32120 $869.67

32124 $922.18

32140 $984.67

32141 $1,510.83

32150 $1,000.57

32151 $999.09

32160 $793.50

32200 $1,131.46

32215 $795.35

32220 $1,581.45

32225 $989.47

32310 $908.13

32320 $1,588.11

32400 $165.65

32405 $415.98

32440 $1,555.20

32442 $3,029.80

32445 $3,501.24

32480 $1,468.68

32482 $1,574.80

32484 $1,421.72

32486 $2,332.06

32488 $2,371.26

65 of 300


ND Medicaid


as of 7/1/2020



32491 $1,461.28

32501 $240.34

32503 $1,781.49

32504 $2,028.49

32505 $926.61

32506 $154.56

32507 $154.56

32540 $1,721.22

32550 $820.12

32551 $158.63

32552 $188.58

32553 $552.42

32554 $230.36

32555 $323.54

32556 $699.21

32557 $643.75

32560 $268.44

32561 $95.77

32562 $86.15

32601 $306.53

32604 $475.14

32606 $458.50

32607 $306.16

32608 $375.67

32609 $256.61

32650 $664.09

32651 $1,088.20

32652 $1,648.38

32653 $1,055.66

32654 $1,162.52

32655 $949.54

32656 $798.68

32658 $710.31

32659 $728.42

32661 $793.50

66 of 300


ND Medicaid


as of 7/1/2020



32662 $887.05

32663 $1,388.81

32664 $842.31

32665 $1,222.42

32666 $864.86

32667 $154.93

32668 $154.93

32669 $1,332.98

32670 $1,591.81

32671 $1,759.68

32672 $1,511.20

32673 $1,208.74

32674 $212.61

32701 $214.09

32800 $941.40

32810 $895.55

32815 $2,774.29

32820 $1,321.88

32851 $3,246.48

32852 $3,525.64

32853 $4,538.41

32854 $4,818.69

32900 $1,413.58

32905 $1,324.84

32906 $1,634.70

32940 $1,224.27

32960 $130.89

32994 $5,744.56

32997 $353.86

32998 $3,666.52

33016 $235.91

33017 $245.52

33018 $281.76

33019 $227.40

33020 $821.23

67 of 300


ND Medicaid


as of 7/1/2020



33025 $766.14

33030 $1,984.12

33031 $2,455.93

33050 $999.09

33120 $2,078.04

33130 $1,358.49

33140 $1,547.81

33141 $130.52

33202 $766.88

33203 $802.01

33206 $457.39

33207 $481.79

33208 $523.58

33210 $163.43

33211 $168.98

33212 $323.54

33213 $337.59

33214 $481.42

33215 $312.45

33216 $375.30

33217 $369.39

33218 $390.09

33220 $378.26

33221 $364.21

33222 $343.51

33223 $412.65

33224 $516.18

33225 $469.59

33226 $495.85

33227 $340.92

33228 $356.45

33229 $377.52

33230 $384.92

33231 $404.15

33233 $234.06

68 of 300


ND Medicaid


as of 7/1/2020



33234 $488.82

33235 $642.27

33236 $779.08

33237 $835.28

33238 $938.45

33240 $367.17

33241 $217.05

33243 $1,364.41

33244 $869.67

33249 $921.81

33250 $1,446.49

33251 $1,615.10

33254 $1,344.07

33255 $1,616.58

33256 $1,924.96

33257 $579.78

33258 $647.45

33259 $841.20

33261 $1,601.05

33262 $376.04

33263 $391.20

33264 $408.21

33265 $1,350.36

33266 $1,832.89

33270 $569.80

33271 $454.80

33272 $349.79

33273 $400.82

33274 $489.19

33275 $534.67

33285 $5,279.40

33286 $134.22

33289 $329.45

33300 $2,431.90

33305 $4,060.31

69 of 300


ND Medicaid


as of 7/1/2020



33310 $1,162.52

33315 $1,898.34

33320 $1,046.78

33321 $1,180.64

33322 $1,382.16

33330 $1,415.43

33335 $1,856.55

33340 $789.06

33361 $1,204.67

33362 $1,311.53

33363 $1,359.97

33364 $1,357.75

33365 $1,439.10

33366 $1,564.45

33367 $624.52

33368 $735.82

33369 $971.35

33390 $1,916.09

33391 $2,276.23

33404 $1,737.12

33405 $2,253.31

33406 $2,856.01

33410 $2,523.97

33411 $3,331.15

33412 $3,127.41

33413 $3,202.84

33414 $2,130.55

33415 $2,019.62

33416 $2,007.79

33417 $1,655.78

33418 $1,794.81

33419 $423.37

33420 $1,441.69

33422 $1,653.56

33425 $2,710.33

70 of 300


ND Medicaid


as of 7/1/2020



33426 $2,364.97

33427 $2,425.61

33430 $2,780.21

33440 $3,397.34

33460 $2,384.57

33463 $3,069.36

33464 $2,424.87

33465 $2,737.32

33468 $2,430.42

33470 $1,230.55

33471 $1,315.97

33474 $2,160.87

33475 $2,317.27

33476 $1,512.31

33477 $1,351.10

33478 $1,562.60

33496 $1,654.30

33500 $1,551.50

33501 $1,110.01

33502 $1,269.75

33503 $1,319.67

33504 $1,456.85

33505 $2,044.02

33506 $2,035.89

33507 $1,708.28

33508 $16.27

33510 $1,921.26

33511 $2,108.36

33512 $2,400.84

33513 $2,464.07

33514 $2,589.05

33516 $2,685.18

33517 $185.62

33518 $407.47

33519 $539.11

71 of 300


ND Medicaid


as of 7/1/2020



33521 $647.08

33522 $725.47

33523 $824.19

33530 $520.62

33533 $1,858.03

33534 $2,182.31

33535 $2,432.64

33536 $2,621.21

33542 $2,606.79

33545 $3,047.92

33548 $2,936.99

33572 $227.77

33600 $1,706.43

33602 $1,656.52

33606 $1,765.22

33608 $1,787.78

33610 $1,762.64

33611 $1,934.94

33612 $1,985.97

33615 $1,981.90

33617 $2,146.45

33619 $2,718.83

33620 $1,636.18

33621 $924.40

33622 $3,402.51

33641 $1,626.20

33645 $1,717.53

33647 $1,802.20

33660 $1,742.67

33665 $1,897.60

33670 $1,955.28

33675 $1,955.28

33676 $2,006.31

33677 $2,084.33

33681 $1,829.19

72 of 300


ND Medicaid


as of 7/1/2020



33684 $1,873.19

33688 $1,868.02

33690 $1,194.32

33692 $1,939.38

33694 $1,934.94

33697 $2,037.74

33702 $1,536.34

33710 $2,033.67

33720 $1,537.08

33722 $1,615.10

33724 $1,526.73

33726 $2,015.18

33730 $1,990.04

33732 $1,637.29

33735 $1,288.61

33736 $1,398.05

33737 $1,290.09

33750 $1,254.96

33755 $1,309.68

33762 $1,274.56

33764 $1,309.68

33766 $1,324.84

33767 $1,412.85

33768 $411.91

33770 $2,098.75

33771 $2,158.65

33774 $1,787.04

33775 $1,840.29

33776 $1,946.04

33777 $1,878.00

33778 $2,330.58

33779 $2,304.70

33780 $2,346.85

33781 $2,291.76

33782 $3,199.89

73 of 300


ND Medicaid


as of 7/1/2020



33783 $3,458.72

33786 $2,258.11

33788 $1,522.66

33800 $980.60

33802 $1,079.32

33803 $1,144.40

33813 $1,233.51

33814 $1,513.79

33820 $962.48

33822 $1,014.25

33824 $1,174.35

33840 $1,232.03

33845 $1,326.32

33851 $1,265.31

33852 $1,390.29

33853 $1,819.95

33858 $3,367.76

33859 $2,420.44

33863 $3,124.46

33864 $3,191.75

33866 $915.52

33871 $3,235.38

33875 $2,717.35

33877 $3,575.93

33880 $1,775.21

33881 $1,523.40

33883 $1,105.95

33884 $387.88

33886 $947.69

33889 $777.60

33891 $946.21

33910 $2,639.70

33915 $1,368.47

33916 $4,179.37

33917 $1,447.97

74 of 300


ND Medicaid


as of 7/1/2020



33920 $1,797.02

33922 $1,380.68

33924 $282.86

33925 $1,703.11

33926 $2,394.92

33927 $2,524.71

33935 $4,906.69

33945 $4,820.90

33946 $308.38

33947 $341.66

33948 $242.19

33949 $234.43

33951 $420.05

33952 $425.59

33953 $468.48

33954 $472.18

33955 $821.23

33956 $826.78

33957 $183.03

33958 $183.03

33959 $231.84

33962 $231.84

33963 $463.31

33964 $488.82

33965 $183.03

33966 $235.91

33967 $257.72

33968 $33.65

33969 $270.29

33970 $351.27

33971 $701.80

33973 $509.53

33974 $885.94

33975 $1,294.52

33976 $1,571.47

75 of 300


ND Medicaid


as of 7/1/2020



33977 $1,115.93

33978 $1,319.30

33979 $1,927.18

33980 $1,762.64

33981 $823.45

33982 $1,934.94

33983 $2,286.58

33984 $281.39

33985 $508.79

33986 $518.40

33987 $206.32

33988 $769.84

33989 $488.82

33990 $422.63

33991 $620.08

33992 $198.19

33993 $173.79

34001 $900.36

34051 $986.88

34101 $593.09

34111 $597.16

34151 $1,376.61

34201 $1,014.62

34203 $940.29

34401 $1,452.04

34421 $738.04

34451 $1,411.74

34471 $1,061.21

34490 $635.61

34501 $879.28

34502 $1,539.67

34510 $1,005.00

34520 $973.94

34530 $925.87

34701 $1,233.14

76 of 300


ND Medicaid


as of 7/1/2020



34702 $1,836.96

34703 $1,358.49

34704 $2,258.11

34705 $1,517.49

34706 $2,285.10

34707 $1,151.43

34708 $1,836.59

34709 $319.84

34710 $797.20

34711 $294.70

34712 $658.17

34713 $123.50

34714 $268.07

34715 $295.44

34716 $368.28

34717 $438.90

34718 $1,227.97

34808 $195.97

34812 $204.11

34813 $233.32

34820 $344.98

34830 $1,732.32

34831 $1,899.45

34832 $1,862.47

34833 $397.49

34834 $127.57

35001 $1,111.12

35002 $1,118.89

35005 $979.86

35011 $993.17

35013 $1,250.15

35021 $1,252.37

35022 $1,432.07

35045 $972.09

35081 $1,709.76

77 of 300


ND Medicaid


as of 7/1/2020



35082 $2,157.91

35091 $1,763.01

35092 $2,569.45

35102 $1,854.71

35103 $2,205.98

35111 $1,306.36

35112 $1,606.97

35121 $1,554.46

35122 $1,858.40

35131 $1,360.34

35132 $1,606.97

35141 $1,090.79

35142 $1,315.60

35151 $1,222.79

35152 $1,374.39

35180 $874.85

35182 $1,777.06

35184 $949.17

35188 $1,240.91

35189 $1,484.21

35190 $758.37

35201 $937.71

35206 $779.08

35207 $767.25

35211 $1,382.16

35216 $2,065.10

35221 $1,458.33

35226 $826.04

35231 $1,269.75

35236 $1,001.67

35241 $1,425.79

35246 $1,553.72

35251 $1,734.17

35256 $1,016.09

35261 $964.70

78 of 300


ND Medicaid


as of 7/1/2020



35266 $859.32

35271 $1,372.54

35276 $1,447.97

35281 $1,614.36

35286 $927.35

35301 $1,120.00

35302 $1,108.90

35303 $1,225.01

35304 $1,259.40

35305 $1,210.59

35306 $437.05

35311 $1,546.33

35321 $884.09

35331 $1,436.14

35341 $1,359.23

35351 $1,268.64

35355 $1,018.68

35361 $1,496.78

35363 $1,596.62

35371 $809.03

35372 $967.66

35390 $157.52

35400 $146.42

35500 $314.66

35501 $1,435.77

35506 $1,252.74

35508 $1,305.62

35509 $1,389.55

35510 $1,208.74

35511 $1,102.25

35512 $1,185.81

35515 $1,305.62

35516 $1,199.49

35518 $1,123.32

35521 $1,206.89

79 of 300


ND Medicaid


as of 7/1/2020



35522 $1,202.82

35523 $1,268.64

35525 $1,122.59

35526 $1,719.00

35531 $1,915.72

35533 $1,481.25

35535 $1,870.98

35536 $1,661.69

35537 $2,049.20

35538 $2,295.83

35539 $2,154.95

35540 $2,401.95

35556 $1,385.11

35558 $1,217.98

35560 $1,675.74

35563 $1,301.18

35565 $1,293.78

35566 $1,650.23

35570 $1,449.08

35571 $1,309.68

35572 $341.29

35583 $1,426.53

35585 $1,652.45

35587 $1,346.29

35600 $253.65

35601 $1,379.94

35606 $1,159.56

35612 $1,027.93

35616 $1,084.13

35621 $1,084.13

35623 $1,291.93

35626 $1,577.76

35631 $1,826.97

35632 $1,776.32

35633 $1,953.43

80 of 300


ND Medicaid


as of 7/1/2020



35634 $1,738.60

35636 $1,567.77

35637 $1,631.74

35638 $1,723.81

35642 $971.35

35645 $931.79

35646 $1,696.45

35647 $1,529.32

35650 $1,005.00

35654 $1,354.05

35656 $1,069.34

35661 $1,073.41

35663 $1,197.65

35665 $1,161.04

35666 $1,261.98

35671 $1,113.34

35681 $79.87

35682 $347.94

35683 $401.19

35685 $195.60

35686 $157.89

35691 $930.68

35693 $822.34

35694 $972.46

35695 $1,009.07

35697 $145.31

35700 $150.12

35701 $444.45

35702 $410.43

35703 $414.13

35800 $724.73

35820 $1,996.32

35840 $1,198.76

35860 $830.48

35870 $1,225.75

81 of 300


ND Medicaid


as of 7/1/2020



35875 $590.87

35876 $937.71

35879 $915.52

35881 $1,009.44

35883 $1,187.29

35884 $1,219.09

35901 $467.37

35903 $563.51

35905 $1,753.76

35907 $1,876.15

36000 $28.84

36002 $158.63

36005 $309.49

36010 $548.72

36011 $902.95

36012 $916.26

36013 $837.13

36014 $869.30

36015 $943.25

36100 $536.52

36140 $498.43

36160 $570.17

36200 $611.58

36215 $1,125.54

36216 $1,186.18

36217 $1,971.55

36218 $238.49

36221 $1,095.22

36222 $1,292.30

36223 $1,662.43

36224 $2,149.03

36225 $1,592.55

36226 $2,031.45

36227 $253.28

36228 $1,372.54

82 of 300


ND Medicaid


as of 7/1/2020



36245 $1,397.32

36246 $889.64

36247 $1,578.87

36248 $142.73

36251 $1,453.52

36252 $1,555.94

36253 $2,312.84

36254 $2,248.87

36260 $654.10

36261 $408.58

36262 $312.45

36400 $27.36

36405 $24.03

36406 $17.01

36410 $17.75

36415 $3.33

36416 $7.40

36420 $47.33

36425 $40.67

36430 $36.24

36440 $52.88

36450 $177.85

36455 $125.35

36456 $105.38

36460 $353.49

36465 $1,579.24

36466 $1,751.91

36470 $112.04

36471 $201.52

36473 $1,481.62

36474 $297.66

36475 $1,419.13

36476 $315.40

36478 $1,099.66

36479 $333.15

83 of 300


ND Medicaid


as of 7/1/2020



36481 $2,007.79

36482 $1,984.86

36483 $157.52

36500 $184.14

36510 $85.78

36511 $113.89

36512 $112.78

36513 $112.04

36514 $705.87

36516 $2,045.13

36522 $2,016.66

36555 $194.86

36556 $220.75

36557 $1,137.01

36558 $845.27

36560 $1,356.27

36561 $1,114.08

36563 $1,227.97

36565 $901.47

36566 $4,866.39

36568 $95.03

36569 $97.62

36570 $1,541.15

36571 $1,351.47

36572 $453.32

36573 $417.09

36575 $167.13

36576 $348.68

36578 $485.49

36580 $227.03

36581 $839.72

36582 $1,029.04

36583 $1,309.68

36584 $364.58

36585 $1,146.62

84 of 300


ND Medicaid


as of 7/1/2020



36589 $170.09

36590 $226.29

36591 $25.51

36592 $28.84

36593 $32.54

36595 $654.47

36596 $126.46

36597 $137.92

36598 $125.72

36600 $31.06

36620 $45.48

36625 $107.23

36640 $119.43

36660 $70.99

36680 $59.90

36800 $125.35

36810 $216.31

36815 $133.11

36818 $687.75

36819 $726.57

36820 $725.10

36821 $660.02

36823 $1,399.16

36825 $790.17

36830 $662.98

36831 $611.95

36832 $751.72

36833 $805.33

36835 $480.32

36838 $1,132.94

36860 $251.44

36861 $137.92

36901 $720.29

36902 $1,355.16

36903 $5,392.92

85 of 300


ND Medicaid


as of 7/1/2020



36904 $2,005.20

36905 $2,520.27

36906 $6,690.77

36907 $719.18

36908 $2,193.03

36909 $2,089.50

37140 $2,317.64

37145 $2,149.77

37160 $2,208.19

37180 $2,122.78

37181 $2,317.64

37182 $850.07

37183 $6,498.87

37184 $2,039.95

37185 $613.43

37186 $1,372.54

37187 $2,013.70

37188 $1,696.45

37191 $2,504.74

37192 $1,383.63

37193 $1,649.12

37197 $1,671.31

37200 $225.18

37211 $389.72

37212 $342.40

37213 $236.28

37214 $124.24

37215 $994.65

37216 $1,018.31

37217 $1,070.45

37218 $817.17

37220 $3,003.17

37221 $4,071.04

37222 $770.21

37223 $1,996.32

86 of 300


ND Medicaid


as of 7/1/2020



37224 $3,575.19

37225 $11,818.57

37226 $10,496.32

37227 $15,198.90

37228 $5,153.69

37229 $11,857.77

37230 $10,658.64

37231 $14,773.31

37232 $1,059.73

37233 $1,295.26

37234 $4,060.68

37235 $4,271.44

37236 $3,510.85

37237 $1,950.10

37238 $3,319.32

37239 $1,535.97

37241 $5,158.12

37242 $7,989.73

37243 $10,095.87

37244 $7,399.97

37246 $2,135.72

37247 $748.39

37248 $1,571.84

37249 $570.91

37252 $1,223.90

37253 $193.38

37500 $625.63

37565 $728.79

37600 $745.43

37605 $726.94

37606 $703.28

37607 $373.83

37609 $318.73

37615 $530.60

37616 $1,102.62

87 of 300


ND Medicaid


as of 7/1/2020



37617 $1,329.65

37618 $389.36

37619 $1,724.18

37650 $452.95

37660 $1,314.49

37700 $244.78

37718 $418.94

37722 $469.22

37735 $573.49

37760 $620.82

37761 $540.59

37765 $449.63

37766 $524.32

37780 $232.58

37785 $360.14

37788 $1,298.96

37790 $500.65

38100 $1,155.49

38101 $1,165.48

38102 $262.16

38115 $1,281.21

38120 $1,057.14

38200 $138.29

38205 $88.37

38206 $88.00

38207 $46.96

38208 $29.58

38209 $12.57

38210 $82.46

38211 $74.69

38212 $49.55

38213 $12.57

38214 $42.89

38215 $49.55

38220 $173.05

88 of 300


ND Medicaid


as of 7/1/2020



38221 $163.43

38222 $180.44

38230 $205.96

38232 $202.26

38240 $245.52

38241 $181.55

38242 $131.63

38243 $126.46

38300 $336.85

38305 $491.41

38308 $458.50

38380 $578.67

38381 $800.53

38382 $679.62

38500 $341.66

38505 $129.05

38510 $534.67

38520 $469.59

38525 $440.75

38530 $570.91

38531 $441.86

38542 $525.43

38550 $518.40

38555 $1,020.16

38562 $717.33

38564 $710.67

38570 $519.88

38571 $681.09

38572 $928.09

38573 $1,181.01

38700 $817.90

38720 $1,357.75

38724 $1,470.53

38740 $701.43

38745 $882.24

89 of 300


ND Medicaid


as of 7/1/2020



38746 $212.24

38747 $266.23

38760 $844.53

38765 $1,310.42

38770 $821.60

38780 $1,051.22

38790 $83.57

38792 $85.78

38794 $308.01

38900 $137.55

39000 $499.17

39010 $784.63

39200 $866.71

39220 $1,131.46

39401 $306.53

39402 $400.45

39501 $856.36

39503 $5,848.83

39540 $872.26

39541 $941.03

39545 $892.60

39560 $802.01

39561 $1,240.54

40490 $129.05

40500 $533.19

40510 $504.72

40520 $512.85

40525 $564.99

40527 $631.55

40530 $562.03

40650 $477.73

40652 $523.58

40654 $596.05

40700 $1,033.47

40701 $1,222.05

90 of 300


ND Medicaid


as of 7/1/2020



40702 $1,026.08

40720 $1,053.81

40761 $1,110.01

40800 $218.16

40801 $312.82

40804 $204.85

40805 $309.12

40806 $103.90

40808 $165.65

40810 $219.27

40812 $298.02

40814 $394.90

40816 $414.87

40818 $381.96

40819 $293.96

40820 $271.77

40830 $289.15

40831 $368.28

40840 $861.17

40842 $938.08

40843 $1,220.57

40844 $1,531.54

40845 $1,507.13

41000 $164.91

41005 $227.03

41006 $357.56

41007 $350.90

41008 $399.71

41009 $429.29

41010 $217.79

41015 $422.26

41016 $472.18

41017 $471.07

41018 $529.12

41019 $502.13

91 of 300


ND Medicaid


as of 7/1/2020



41100 $181.55

41105 $183.40

41108 $161.21

41110 $228.51

41112 $347.94

41113 $377.52

41114 $634.87

41115 $263.27

41116 $345.35

41120 $1,094.85

41130 $1,348.14

41135 $2,215.96

41140 $2,231.12

41145 $2,819.77

41150 $2,243.69

41153 $2,441.51

41155 $3,073.80

41250 $288.41

41251 $317.25

41252 $330.19

41510 $462.94

41512 $678.14

41520 $368.28

41530 $993.54

41800 $305.79

41805 $310.23

41806 $418.20

41822 $357.19

41823 $525.43

41825 $226.29

41826 $326.50

41827 $464.05

41828 $357.56

41830 $471.81

41872 $464.05

92 of 300


ND Medicaid


as of 7/1/2020



41874 $408.21

42000 $162.69

42100 $153.08

42104 $225.18

42106 $277.32

42107 $480.32

42120 $1,031.99

42140 $292.85

42145 $706.98

42160 $243.67

42180 $258.46

42182 $335.37

42200 $966.18

42205 $1,005.00

42210 $1,121.85

42215 $733.60

42220 $604.55

42225 $1,011.66

42226 $908.13

42227 $848.96

42235 $744.69

42260 $853.40

42280 $185.25

42281 $237.38

42300 $220.38

42305 $436.68

42310 $181.92

42320 $264.38

42330 $239.60

42335 $418.20

42340 $512.85

42400 $107.23

42405 $309.49

42408 $547.24

42409 $376.78

93 of 300


ND Medicaid


as of 7/1/2020



42410 $634.87

42415 $1,072.67

42420 $1,204.67

42425 $850.44

42426 $1,371.43

42440 $420.05

42450 $475.88

42500 $450.74

42505 $575.71

42507 $511.01

42509 $844.90

42510 $627.11

42550 $160.11

42600 $526.54

42650 $80.98

42660 $124.61

42665 $356.45

42700 $197.08

42720 $462.57

42725 $820.49

42800 $162.32

42804 $205.59

42806 $229.62

42808 $235.54

42809 $207.80

42810 $397.86

42815 $557.60

42820 $294.70

42821 $307.27

42825 $268.81

42826 $256.98

42830 $212.98

42831 $230.73

42835 $197.82

42836 $246.26

94 of 300


ND Medicaid


as of 7/1/2020



42842 $1,031.99

42844 $1,419.87

42845 $2,278.82

42860 $193.75

42870 $605.66

42890 $1,456.85

42892 $1,914.61

42894 $2,416.37

42900 $339.81

42950 $823.45

42953 $986.51

42955 $781.67

42960 $168.98

42961 $425.59

42962 $524.69

42970 $418.57

42971 $461.83

42972 $516.55

43020 $563.88

43030 $528.38

43045 $1,296.74

43100 $641.16

43101 $1,002.04

43107 $2,970.27

43108 $4,421.20

43112 $3,468.70

43113 $4,319.88

43116 $4,946.25

43117 $3,233.53

43118 $3,602.55

43121 $2,837.15

43122 $2,553.92

43123 $4,478.88

43124 $3,782.25

43130 $796.46

95 of 300


ND Medicaid


as of 7/1/2020



43135 $1,462.39

43180 $555.75

43191 $157.15

43192 $172.31

43193 $171.94

43194 $194.86

43195 $187.10

43196 $199.67

43197 $199.30

43198 $220.01

43200 $250.70

43201 $250.33

43202 $352.01

43204 $139.40

43205 $145.31

43206 $296.18

43210 $438.53

43211 $241.82

43212 $191.90

43213 $1,281.58

43214 $197.82

43215 $398.23

43216 $408.58

43217 $417.09

43220 $1,059.73

43226 $370.87

43227 $648.19

43229 $724.73

43231 $164.54

43232 $205.96

43233 $234.06

43235 $290.26

43236 $388.62

43237 $201.52

43238 $239.23

96 of 300


ND Medicaid


as of 7/1/2020



43239 $387.88

43240 $404.15

43241 $146.05

43242 $271.03

43243 $244.04

43244 $252.91

43245 $613.06

43246 $204.85

43247 $383.44

43248 $403.41

43249 $1,142.18

43250 $448.15

43251 $494.37

43252 $335.00

43253 $271.40

43254 $278.43

43255 $683.68

43257 $239.23

43259 $233.32

43260 $332.41

43261 $348.68

43262 $367.91

43263 $367.91

43264 $374.93

43265 $446.67

43266 $223.33

43270 $743.95

43273 $123.50

43274 $476.99

43275 $387.51

43276 $496.58

43277 $389.72

43278 $446.30

43279 $1,289.35

43280 $1,082.28

97 of 300


ND Medicaid


as of 7/1/2020



43281 $1,543.74

43282 $1,734.90

43283 $157.15

43284 $653.36

43285 $672.59

43286 $3,180.66

43287 $3,577.41

43288 $3,775.23

43300 $630.07

43305 $1,109.64

43310 $1,473.49

43312 $1,579.61

43313 $2,715.13

43314 $2,920.35

43320 $1,399.16

43325 $1,360.34

43327 $823.08

43328 $1,119.26

43330 $1,337.78

43331 $1,332.98

43332 $1,158.08

43333 $1,264.94

43334 $1,243.13

43335 $1,328.54

43336 $1,442.43

43337 $1,537.82

43338 $114.99

43340 $1,381.42

43341 $1,393.25

43351 $1,311.90

43352 $1,062.31

43360 $2,236.67

43361 $2,694.80

43400 $1,523.77

43405 $1,449.82

98 of 300


ND Medicaid


as of 7/1/2020



43410 $1,043.46

43415 $2,560.20

43420 $1,032.36

43425 $1,434.66

43450 $177.48

43453 $924.03

43460 $218.90

43500 $788.32

43501 $1,351.10

43502 $1,527.10

43510 $951.39

43520 $689.97

43605 $842.31

43610 $984.30

43611 $1,227.23

43620 $1,983.38

43621 $2,269.94

43622 $2,311.36

43631 $1,454.26

43632 $2,035.89

43633 $1,925.70

43634 $2,126.11

43635 $112.41

43640 $1,182.86

43641 $1,206.52

43644 $1,738.60

43645 $1,851.01

43651 $658.54

43652 $767.99

43653 $580.15

43752 $41.78

43753 $22.19

43754 $189.69

43755 $178.96

43756 $261.05

99 of 300


ND Medicaid


as of 7/1/2020



43757 $358.30

43761 $124.24

43762 $236.28

43763 $351.64

43770 $1,129.61

43771 $1,282.32

43772 $953.61

43773 $1,282.32

43774 $963.59

43775 $1,111.49

43800 $935.12

43810 $1,019.79

43820 $1,347.40

43825 $1,313.01

43830 $707.35

43831 $608.62

43832 $1,044.20

43840 $1,364.04

43842 $1,203.19

43843 $1,285.65

43845 $1,952.32

43846 $1,629.52

43847 $1,808.49

43848 $1,940.49

43850 $1,631.00

43855 $1,691.64

43860 $1,641.73

43865 $1,711.24

43870 $715.48

43880 $1,597.35

43886 $369.76

43887 $332.04

43888 $467.74

44005 $1,096.70

44010 $868.19

100 of 300


ND Medicaid


as of 7/1/2020



44015 $141.62

44020 $976.90

44021 $978.75

44025 $988.36

44050 $938.82

44055 $1,493.08

44100 $110.93

44110 $853.40

44111 $989.47

44120 $1,226.49

44121 $241.45

44125 $1,185.44

44126 $2,469.24

44127 $2,852.31

44128 $242.56

44130 $1,320.41

44139 $120.91

44140 $1,347.40

44141 $1,832.52

44143 $1,670.94

44144 $1,775.21

44145 $1,664.28

44146 $2,127.59

44147 $1,946.41

44150 $1,879.11

44151 $2,165.67

44155 $2,093.57

44156 $2,318.75

44157 $2,197.84

44158 $2,252.57

44160 $1,248.30

44180 $923.66

44186 $654.84

44187 $1,114.45

44188 $1,233.51

101 of 300


ND Medicaid


as of 7/1/2020



44202 $1,391.03

44203 $240.71

44204 $1,547.44

44205 $1,346.29

44206 $1,759.31

44207 $1,831.04

44208 $1,999.28

44210 $1,797.76

44211 $2,174.55

44212 $2,072.12

44213 $187.84

44227 $1,672.79

44300 $845.64

44310 $1,049.74

44312 $601.60

44314 $1,016.83

44316 $1,416.54

44320 $1,208.37

44322 $1,019.42

44340 $630.44

44345 $1,059.36

44346 $1,191.36

44360 $147.90

44361 $163.43

44363 $197.45

44364 $210.76

44365 $187.10

44366 $247.37

44369 $253.65

44370 $274.73

44372 $246.26

44373 $197.08

44376 $292.85

44377 $308.01

44378 $396.38

102 of 300


ND Medicaid


as of 7/1/2020



44379 $421.15

44380 $190.43

44381 $1,027.93

44382 $298.39

44384 $157.52

44385 $208.17

44386 $312.45

44388 $313.55

44389 $415.61

44390 $407.10

44391 $703.65

44392 $381.22

44394 $438.16

44401 $2,957.69

44402 $269.92

44403 $313.19

44404 $413.39

44405 $581.63

44406 $236.28

44407 $283.97

44408 $238.49

44500 $19.97

44602 $1,412.85

44603 $1,625.46

44604 $1,061.58

44605 $1,310.05

44615 $1,081.17

44620 $873.00

44625 $1,023.12

44626 $1,605.49

44640 $1,405.08

44650 $1,454.26

44660 $1,353.31

44661 $1,561.12

44680 $1,065.27

103 of 300


ND Medicaid


as of 7/1/2020



44700 $1,019.05

44701 $169.35

44705 $114.62

44720 $273.25

44721 $382.33

44800 $775.01

44820 $840.46

44850 $749.50

44900 $785.74

44950 $645.23

44955 $83.94

44960 $879.65

44970 $604.55

45000 $435.21

45005 $301.35

45020 $579.78

45100 $305.79

45108 $374.56

45110 $1,858.40

45111 $1,097.81

45112 $1,889.09

45113 $1,924.59

45114 $1,818.10

45116 $1,585.89

45119 $1,958.98

45120 $1,599.20

45121 $1,745.63

45123 $1,132.94

45126 $2,813.49

45130 $1,103.36

45135 $1,328.54

45136 $1,841.76

45150 $422.26

45160 $1,027.93

45171 $618.24

104 of 300


ND Medicaid


as of 7/1/2020



45172 $830.85

45190 $717.70

45300 $127.94

45303 $1,003.52

45305 $167.50

45307 $192.27

45308 $188.21

45309 $194.12

45315 $211.13

45317 $208.54

45320 $205.96

45321 $103.53

45327 $117.21

45330 $181.92

45331 $286.93

45332 $274.36

45333 $325.76

45334 $551.31

45335 $277.69

45337 $118.32

45338 $293.59

45340 $474.77

45341 $127.57

45342 $174.90

45346 $2,887.81

45347 $158.63

45349 $204.48

45350 $654.47

45378 $340.55

45379 $439.64

45380 $440.75

45381 $437.42

45382 $730.64

45384 $489.56

45385 $458.50

105 of 300


ND Medicaid


as of 7/1/2020



45386 $635.24

45388 $3,053.83

45389 $298.02

45390 $342.77

45391 $265.49

45392 $313.19

45393 $259.20

45395 $1,995.58

45397 $2,176.40

45398 $815.32

45400 $1,154.75

45402 $1,536.34

45500 $569.43

45505 $610.10

45520 $163.06

45540 $1,075.26

45541 $957.67

45550 $1,483.47

45560 $707.72

45562 $1,139.59

45563 $1,663.91

45800 $1,272.71

45805 $1,475.33

45820 $1,276.03

45825 $1,542.63

45900 $212.98

45905 $171.94

45910 $195.97

45915 $355.71

45990 $107.60

46020 $289.52

46030 $148.64

46040 $560.18

46045 $445.93

46050 $227.03

106 of 300


ND Medicaid


as of 7/1/2020



46060 $492.52

46070 $270.29

46080 $276.58

46083 $198.93

46200 $478.10

46220 $236.65

46221 $283.97

46230 $302.83

46250 $488.45

46255 $532.45

46257 $436.31

46258 $477.73

46260 $488.45

46261 $535.41

46262 $570.17

46270 $538.74

46275 $569.43

46280 $486.60

46285 $566.47

46288 $565.36

46320 $203.74

46500 $310.60

46505 $306.16

46600 $106.86

46601 $147.90

46604 $699.21

46606 $266.60

46607 $207.43

46608 $278.06

46610 $265.12

46611 $210.02

46612 $322.06

46614 $152.71

46615 $166.02

46700 $671.85

107 of 300


ND Medicaid


as of 7/1/2020



46705 $569.80

46706 $178.59

46707 $503.24

46710 $1,116.30

46712 $2,234.82

46715 $555.75

46716 $1,229.45

46730 $1,983.01

46735 $2,283.26

46740 $2,163.82

46742 $2,502.15

46744 $3,534.89

46746 $3,896.51

46748 $4,225.59

46750 $769.10

46751 $668.15

46753 $621.93

46754 $336.48

46760 $1,126.65

46761 $940.29

46900 $245.15

46910 $267.70

46916 $255.50

46917 $437.42

46922 $303.57

46924 $560.55

46930 $222.22

46940 $254.76

46942 $243.30

46945 $344.24

46946 $387.51

46947 $390.09

46948 $449.26

47000 $324.65

47001 $103.53

108 of 300


ND Medicaid


as of 7/1/2020



47010 $1,217.61

47015 $1,170.28

47100 $853.40

47120 $2,339.83

47122 $3,433.20

47125 $3,079.71

47130 $3,306.75

47135 $5,387.00

47140 $3,567.06

47141 $4,267.01

47142 $4,703.32

47146 $326.87

47147 $381.59

47300 $1,135.90

47350 $1,375.87

47360 $1,881.33

47361 $3,035.34

47362 $1,456.48

47370 $1,252.74

47371 $1,259.77

47380 $1,451.30

47381 $1,482.73

47382 $4,608.29

47383 $7,197.71

47400 $2,157.54

47420 $1,347.03

47425 $1,372.54

47460 $1,275.67

47480 $888.16

47490 $346.83

47531 $404.15

47532 $884.83

47533 $1,314.49

47534 $1,492.34

47535 $1,035.69

109 of 300


ND Medicaid


as of 7/1/2020



47536 $729.53

47537 $470.70

47538 $4,498.11

47539 $4,953.28

47540 $5,053.85

47541 $1,268.64

47542 $541.70

47543 $482.53

47544 $1,041.24

47550 $164.54

47552 $283.23

47553 $285.45

47554 $513.96

47555 $339.44

47556 $384.55

47562 $661.87

47563 $720.29

47564 $1,119.26

47570 $777.97

47600 $1,073.78

47605 $1,129.24

47610 $1,259.03

47612 $1,278.99

47620 $1,380.31

47700 $1,063.05

47701 $1,742.67

47711 $1,564.82

47712 $2,001.50

47715 $1,337.04

47720 $1,161.41

47721 $1,360.71

47740 $1,319.67

47741 $1,481.99

47760 $2,257.00

47765 $3,039.41

110 of 300


ND Medicaid


as of 7/1/2020



47780 $2,477.75

47785 $3,251.28

47800 $1,584.04

47801 $1,121.11

47802 $1,532.65

47900 $1,369.95

48000 $1,886.51

48001 $2,309.14

48020 $1,183.23

48100 $890.38

48102 $561.66

48105 $2,853.42

48120 $1,111.86

48140 $1,567.77

48145 $1,636.92

48146 $1,891.31

48148 $1,254.22

48150 $3,120.76

48152 $2,896.31

48153 $3,108.56

48154 $2,908.89

48155 $1,821.43

48400 $106.86

48500 $1,157.71

48510 $1,104.10

48520 $1,097.44

48540 $1,312.64

48545 $1,349.62

48547 $1,795.18

48548 $1,669.46

48552 $234.80

48554 $2,582.76

48556 $1,282.69

49000 $773.53

49002 $1,049.37

111 of 300


ND Medicaid


as of 7/1/2020



49010 $928.46

49013 $442.60

49014 $366.43

49020 $1,601.05

49040 $1,007.22

49060 $1,107.06

49062 $770.95

49082 $211.87

49083 $313.19

49084 $108.71

49180 $177.11

49185 $1,231.66

49203 $1,202.82

49204 $1,533.39

49205 $1,755.98

49215 $2,232.23

49220 $975.79

49250 $594.20

49255 $796.09

49320 $330.93

49321 $347.94

49322 $376.78

49323 $645.97

49324 $390.83

49325 $416.35

49326 $188.21

49327 $130.15

49400 $149.38

49402 $860.43

49405 $922.92

49406 $922.55

49407 $755.79

49411 $509.16

49412 $82.09

49418 $1,253.85

112 of 300


ND Medicaid


as of 7/1/2020



49419 $439.27

49421 $227.77

49422 $221.85

49423 $625.63

49424 $175.64

49425 $725.83

49426 $670.74

49427 $39.93

49428 $432.99

49429 $459.61

49435 $119.06

49436 $188.21

49440 $978.38

49441 $1,105.58

49442 $927.35

49446 $941.77

49450 $691.45

49451 $748.39

49452 $915.52

49460 $766.88

49465 $159.37

49491 $799.42

49492 $961.37

49495 $411.17

49496 $617.50

49500 $416.35

49501 $608.62

49505 $525.06

49507 $589.76

49520 $635.24

49521 $720.29

49525 $577.19

49540 $678.14

49550 $579.78

49553 $634.87

113 of 300


ND Medicaid


as of 7/1/2020



49555 $605.66

49557 $726.94

49560 $741.73

49561 $932.53

49565 $772.42

49566 $941.40

49568 $266.60

49570 $420.78

49572 $520.99

49580 $337.59

49582 $486.60

49585 $449.63

49587 $480.32

49590 $576.08

49600 $736.56

49605 $4,931.46

49606 $1,135.90

49610 $694.04

49611 $611.95

49650 $433.36

49651 $564.25

49652 $748.02

49653 $933.64

49654 $848.59

49655 $1,037.17

49656 $919.59

49657 $1,323.73

49900 $824.56

49904 $1,413.22

49905 $353.86

50010 $747.65

50020 $1,041.98

50040 $948.06

50045 $958.41

50060 $1,171.39

114 of 300


ND Medicaid


as of 7/1/2020



50065 $1,242.02

50070 $1,217.61

50075 $1,497.52

50080 $893.34

50081 $1,312.64

50100 $1,083.02

50120 $976.16

50125 $1,009.81

50130 $1,061.94

50135 $1,152.91

50200 $567.95

50205 $758.74

50220 $1,070.45

50225 $1,229.45

50230 $1,313.38

50234 $1,335.20

50236 $1,504.92

50240 $1,361.08

50250 $1,250.52

50280 $981.34

50290 $924.03

50320 $1,512.68

50327 $216.31

50328 $189.32

50329 $180.44

50340 $954.72

50360 $2,425.98

50365 $2,886.70

50370 $1,215.02

50380 $2,022.58

50382 $1,149.21

50384 $937.71

50385 $1,130.72

50386 $773.90

50387 $574.60

115 of 300


ND Medicaid


as of 7/1/2020



50389 $393.42

50390 $99.46

50391 $126.83

50396 $121.28

50400 $1,193.21

50405 $1,434.29

50430 $592.72

50431 $270.29

50432 $928.83

50433 $1,201.71

50434 $957.67

50435 $589.76

50436 $155.67

50437 $260.68

50500 $1,248.67

50520 $1,160.67

50525 $1,471.27

50526 $1,576.65

50540 $1,179.16

50541 $942.51

50542 $1,198.02

50543 $1,529.69

50544 $1,277.88

50545 $1,373.65

50546 $1,233.88

50547 $1,618.06

50548 $1,381.42

50551 $371.24

50553 $396.75

50555 $424.85

50557 $431.88

50561 $488.82

50562 $594.94

50570 $503.61

50572 $544.65

116 of 300


ND Medicaid


as of 7/1/2020



50574 $579.41

50575 $732.49

50576 $577.93

50580 $622.67

50590 $761.33

50592 $3,361.10

50593 $4,544.33

50600 $964.70

50605 $1,002.41

50606 $652.99

50610 $971.35

50620 $929.20

50630 $917.37

50650 $1,066.01

50660 $1,175.09

50684 $121.65

50686 $145.68

50688 $80.61

50690 $112.04

50693 $1,090.42

50694 $1,209.48

50695 $1,464.98

50700 $951.76

50705 $1,990.78

50706 $990.21

50715 $1,221.68

50722 $1,048.63

50725 $1,133.31

50727 $523.21

50728 $749.50

50740 $1,225.75

50750 $1,185.44

50760 $1,151.06

50770 $1,185.44

50780 $1,132.94

117 of 300


ND Medicaid


as of 7/1/2020



50782 $1,104.84

50783 $1,158.45

50785 $1,244.24

50800 $951.02

50810 $1,403.97

50815 $1,257.92

50820 $1,347.77

50825 $1,699.04

50830 $1,851.01

50840 $1,264.20

50845 $1,286.76

50860 $972.09

50900 $866.34

50920 $905.91

50930 $1,132.57

50940 $912.19

50945 $998.72

50947 $1,423.57

50948 $1,308.20

50951 $388.62

50953 $411.54

50955 $439.27

50957 $443.34

50961 $399.71

50970 $379.74

50972 $367.17

50974 $484.38

50976 $477.73

50980 $365.32

51020 $482.90

51030 $486.23

51040 $298.39

51045 $509.16

51050 $485.49

51060 $599.38

118 of 300


ND Medicaid


as of 7/1/2020



51065 $596.42

51080 $421.15

51100 $70.25

51101 $147.90

51102 $245.15

51500 $655.21

51520 $612.69

51525 $882.98

51530 $792.39

51535 $802.74

51550 $986.14

51555 $1,297.85

51565 $1,333.72

51570 $1,513.42

51575 $1,871.71

51580 $1,947.89

51585 $2,167.89

51590 $1,984.12

51595 $2,245.91

51596 $2,415.63

51597 $2,352.40

51600 $215.57

51605 $39.56

51610 $124.61

51700 $77.28

51701 $45.85

51702 $63.23

51703 $143.84

51705 $97.99

51710 $136.44

51715 $352.38

51720 $86.15

51725 $220.38

51725 26 $78.02

51725 TC $142.36

119 of 300


ND Medicaid


as of 7/1/2020



51726 $301.35

51726 26 $87.26

51726 TC $214.09

51727 $360.88

51727 26 $109.82

51727 TC $251.07

51728 $366.06

51728 26 $108.34

51728 TC $257.72

51729 $389.36

51729 26 $130.52

51729 TC $258.83

51736 $14.42

51736 26 $8.87

51736 TC $5.55

51741 $14.42

51741 26 $8.87

51741 TC $5.55

51784 $69.14

51784 26 $39.19

51784 TC $29.95

51785 $384.55

51785 26 $89.85

51785 TC $294.70

51792 $258.09

51792 26 $56.57

51792 TC $201.52

51797 $168.98

51797 26 $41.41

51797 TC $127.57

51798 $10.35

51800 $1,070.82

51820 $1,114.82

51840 $700.32

51841 $813.47

120 of 300


ND Medicaid


as of 7/1/2020



51845 $599.01

51860 $761.33

51865 $919.96

51880 $478.47

51900 $847.86

51920 $785.37

51925 $1,083.76

51940 $1,686.10

51960 $1,423.57

51980 $733.97

51990 $767.62

51992 $858.21

52000 $218.16

52001 $427.81

52005 $304.31

52007 $492.89

52010 $412.28

52204 $400.08

52214 $761.70

52224 $794.98

52234 $251.81

52235 $295.44

52240 $401.93

52250 $245.15

52260 $215.57

52265 $394.16

52270 $416.72

52275 $546.13

52276 $271.03

52277 $330.93

52281 $332.78

52282 $344.98

52283 $335.74

52285 $334.26

52287 $372.35

121 of 300


ND Medicaid


as of 7/1/2020



52290 $249.96

52300 $286.56

52301 $296.92

52305 $285.45

52310 $299.50

52315 $479.58

52317 $908.50

52318 $485.12

52320 $252.54

52325 $327.98

52327 $268.81

52330 $602.34

52332 $472.92

52334 $187.47

52341 $291.00

52342 $316.51

52343 $352.75

52344 $377.89

52345 $404.15

52346 $457.39

52351 $309.86

52352 $363.10

52353 $401.93

52354 $427.44

52355 $478.84

52356 $425.96

52400 $490.67

52402 $273.25

52441 $1,422.09

52442 $1,039.76

52450 $485.49

52500 $503.98

52601 $749.87

52630 $414.50

52640 $326.87

122 of 300


ND Medicaid


as of 7/1/2020



52647 $1,689.42

52648 $1,741.56

52649 $848.96

52700 $454.43

53000 $152.71

53010 $304.31

53020 $99.46

53025 $69.88

53040 $404.15

53060 $190.80

53080 $432.62

53085 $668.52

53200 $161.95

53210 $801.64

53215 $954.35

53220 $465.16

53230 $625.63

53235 $651.88

53240 $436.68

53250 $407.84

53260 $209.65

53265 $230.73

53270 $214.46

53275 $269.92

53400 $825.30

53405 $898.14

53410 $1,006.48

53415 $1,161.78

53420 $865.60

53425 $963.22

53430 $995.39

53431 $1,185.81

53440 $774.64

53442 $806.81

53444 $816.43

123 of 300


ND Medicaid


as of 7/1/2020



53445 $776.86

53446 $661.13

53447 $831.59

53448 $1,314.49

53449 $630.07

53450 $421.15

53460 $471.44

53500 $768.36

53502 $500.28

53505 $499.91

53510 $650.40

53515 $818.64

53520 $573.86

53600 $87.26

53601 $83.20

53605 $66.19

53620 $152.71

53621 $144.21

53660 $72.84

53661 $71.73

53665 $39.19

53850 $1,627.67

53852 $1,577.39

53854 $1,880.22

53855 $776.12

53860 $2,201.17

54000 $162.69

54001 $200.04

54015 $314.66

54050 $139.03

54055 $130.15

54056 $145.31

54057 $143.10

54060 $194.12

54065 $227.03

124 of 300


ND Medicaid


as of 7/1/2020



54100 $205.96

54105 $278.43

54110 $642.64

54111 $823.08

54112 $963.96

54115 $468.48

54120 $650.03

54125 $837.13

54130 $1,226.49

54135 $1,553.35

54150 $157.89

54160 $227.40

54161 $202.63

54162 $265.86

54163 $224.44

54164 $198.93

54200 $114.99

54205 $548.35

54220 $217.79

54230 $103.16

54231 $146.05

54235 $90.96

54240 $106.49

54240 26 $67.30

54240 TC $39.19

54250 $126.09

54250 26 $113.52

54250 TC $12.57

54300 $664.09

54304 $770.95

54308 $736.56

54312 $842.31

54316 $1,024.60

54318 $732.49

54322 $804.22

125 of 300


ND Medicaid


as of 7/1/2020



54324 $996.13

54326 $971.35

54328 $965.07

54332 $1,041.24

54336 $1,222.79

54340 $586.44

54344 $973.57

54348 $1,040.87

54352 $1,455.74

54360 $742.10

54380 $822.71

54385 $956.56

54390 $1,276.40

54400 $547.24

54401 $679.25

54405 $832.33

54406 $752.46

54408 $813.47

54410 $885.94

54411 $1,058.62

54415 $545.02

54416 $733.23

54417 $924.76

54420 $724.73

54430 $658.17

54435 $427.81

54437 $695.15

54438 $1,375.13

54450 $70.62

54500 $76.17

54505 $216.31

54512 $554.27

54520 $335.37

54522 $606.77

54530 $522.10

126 of 300


ND Medicaid


as of 7/1/2020



54535 $766.14

54550 $506.94

54560 $707.35

54600 $466.63

54620 $308.01

54640 $445.93

54650 $732.86

54660 $368.28

54670 $419.68

54680 $810.51

54690 $675.18

54692 $779.82

54700 $219.64

54800 $129.05

54830 $383.44

54840 $331.30

54860 $431.14

54861 $584.22

54865 $369.76

54900 $824.19

54901 $1,087.83

55000 $122.02

55040 $347.20

55041 $525.80

55060 $391.57

55100 $231.10

55110 $398.97

55120 $364.58

55150 $506.20

55175 $373.83

55180 $712.15

55200 $425.96

55250 $374.20

55300 $191.53

55400 $514.33

127 of 300


ND Medicaid


as of 7/1/2020



55500 $402.67

55520 $459.24

55530 $362.36

55535 $443.34

55540 $555.75

55550 $441.86

55600 $434.10

55605 $538.37

55650 $738.78

55680 $357.19

55700 $256.98

55705 $273.62

55706 $384.55

55720 $465.90

55725 $611.95

55801 $1,125.91

55810 $1,346.29

55812 $1,653.19

55815 $1,810.70

55821 $898.51

55831 $972.46

55840 $1,203.19

55842 $1,203.56

55845 $1,400.64

55860 $900.36

55862 $1,127.39

55865 $1,372.54

55866 $1,482.73

55870 $180.44

55873 $6,460.78

55874 $3,215.05

55875 $794.24

55876 $150.49

55920 $471.81

56405 $131.63

128 of 300


ND Medicaid


as of 7/1/2020



56420 $160.47

56440 $185.25

56441 $169.35

56442 $48.07

56501 $168.98

56515 $258.83

56605 $92.81

56606 $39.19

56620 $566.10

56625 $659.28

56630 $956.56

56631 $1,193.95

56632 $1,423.57

56633 $1,233.51

56634 $1,301.55

56637 $1,510.09

56640 $1,529.32

56700 $201.15

56740 $314.66

56800 $253.65

56805 $1,184.33

56810 $273.25

56820 $122.39

56821 $163.06

57000 $201.15

57010 $458.50

57020 $112.41

57022 $180.07

57023 $323.17

57061 $145.68

57065 $227.40

57100 $98.73

57105 $163.43

57106 $528.75

57107 $1,466.46

129 of 300


ND Medicaid


as of 7/1/2020



57109 $1,739.34

57110 $921.44

57111 $1,739.34

57112 $1,859.88

57120 $535.04

57130 $211.87

57135 $227.77

57150 $55.09

57155 $394.90

57156 $222.96

57160 $69.88

57170 $72.10

57180 $178.96

57200 $326.13

57210 $392.31

57220 $343.51

57230 $419.31

57240 $618.97

57250 $621.93

57260 $791.28

57265 $887.05

57267 $258.46

57268 $509.16

57270 $826.78

57280 $983.93

57282 $538.74

57283 $714.74

57284 $845.27

57285 $702.91

57287 $735.82

57288 $751.35

57289 $799.42

57291 $554.27

57292 $843.05

57295 $504.72

130 of 300


ND Medicaid


as of 7/1/2020



57296 $967.66

57300 $602.71

57305 $979.49

57307 $1,082.28

57308 $677.40

57310 $495.48

57311 $560.18

57320 $563.88

57330 $780.19

57335 $1,196.17

57400 $134.22

57410 $108.34

57415 $173.79

57420 $128.68

57421 $173.05

57423 $945.84

57425 $999.46

57426 $879.65

57452 $123.13

57454 $167.13

57455 $158.26

57456 $149.01

57460 $316.14

57461 $353.86

57500 $148.27

57505 $133.11

57510 $154.56

57511 $178.96

57513 $181.92

57520 $342.77

57522 $294.33

57530 $369.76

57531 $1,799.98

57540 $804.96

57545 $848.22

131 of 300


ND Medicaid


as of 7/1/2020



57550 $431.88

57555 $626.37

57556 $593.83

57558 $147.90

57700 $345.35

57720 $331.30

57800 $72.10

58100 $99.83

58110 $51.77

58120 $288.04

58140 $945.84

58145 $573.86

58146 $1,181.01

58150 $1,029.41

58152 $1,276.77

58180 $979.86

58200 $1,374.39

58210 $1,842.87

58240 $2,951.41

58260 $853.03

58262 $946.21

58263 $1,015.73

58267 $1,088.57

58270 $909.23

58275 $1,009.81

58280 $1,080.80

58285 $1,425.79

58290 $1,176.57

58291 $1,275.67

58292 $1,342.59

58293 $1,395.10

58294 $1,245.71

58300 $94.29

58301 $103.90

58340 $202.26

132 of 300


ND Medicaid


as of 7/1/2020



58346 $494.37

58353 $1,043.46

58356 $1,904.99

58400 $465.90

58410 $830.48

58520 $813.10

58540 $935.12

58541 $743.21

58542 $844.90

58543 $857.47

58544 $923.66

58545 $916.63

58546 $1,142.92

58548 $1,902.04

58550 $901.10

58552 $1,003.52

58553 $1,149.58

58554 $1,340.74

58555 $334.26

58558 $1,452.41

58559 $292.48

58560 $321.69

58561 $367.54

58562 $406.36

58563 $2,043.28

58565 $1,888.35

58570 $810.51

58571 $914.04

58572 $1,051.59

58573 $1,233.14

58575 $1,933.09

58600 $376.78

58605 $341.29

58611 $78.39

58615 $255.87

133 of 300


ND Medicaid


as of 7/1/2020



58660 $688.86

58661 $662.98

58662 $725.47

58670 $377.52

58671 $377.15

58672 $749.50

58673 $814.21

58674 $833.43

58700 $803.85

58720 $759.48

58740 $910.71

58760 $836.02

58770 $878.55

58800 $354.23

58805 $428.55

58820 $336.11

58822 $725.47

58825 $720.29

58900 $437.79

58920 $726.20

58925 $771.32

58940 $550.57

58943 $1,186.18

58950 $1,152.54

58951 $1,456.48

58952 $1,654.30

58953 $2,027.38

58954 $2,196.73

58956 $1,378.46

58957 $1,599.94

58958 $1,769.29

58960 $985.04

58970 $238.86

58976 $259.57

59000 $121.65

134 of 300


ND Medicaid


as of 7/1/2020



59001 $176.00

59012 $198.93

59015 $155.30

59020 $70.62

59020 26 $36.61

59020 TC $34.02

59025 $48.81

59025 26 $29.21

59025 TC $19.60

59030 $110.93

59050 $50.29

59051 $41.41

59070 $402.30

59072 $514.70

59074 $385.66

59076 $514.70

59100 $841.20

59120 $802.01

59121 $802.74

59130 $933.27

59135 $922.18

59136 $884.83

59140 $410.06

59150 $777.97

59151 $759.11

59160 $241.82

59200 $90.59

59300 $215.20

59320 $149.38

59325 $238.49

59350 $275.84

59400 $2,120.19

59409 $801.64

59410 $1,034.21

59412 $101.68

135 of 300


ND Medicaid


as of 7/1/2020



59414 $89.85

59425 $469.59

59426 $837.50

59430 $208.54

59510 $2,337.61

59514 $901.47

59515 $1,252.74

59525 $476.62

59610 $2,215.59

59612 $898.88

59614 $1,118.15

59618 $2,364.97

59620 $931.05

59622 $1,293.78

59812 $342.40

59820 $413.39

59821 $410.06

59830 $450.74

59840 $237.01

59841 $405.62

59850 $384.18

59851 $414.13

59852 $569.80

59855 $418.20

59856 $489.93

59857 $572.39

59866 $235.54

59870 $509.53

59871 $131.26

60000 $179.70

60100 $114.99

60200 $671.48

60210 $712.89

60212 $1,027.93

60220 $713.63

136 of 300


ND Medicaid


as of 7/1/2020



60225 $942.14

60240 $925.50

60252 $1,330.76

60254 $1,684.99

60260 $1,100.40

60270 $1,374.76

60271 $1,064.90

60280 $454.43

60281 $600.49

60300 $117.95

60500 $973.57

60502 $1,301.18

60505 $1,400.64

60512 $242.93

60520 $1,049.37

60521 $1,116.67

60522 $1,358.12

60540 $1,080.06

60545 $1,242.39

60600 $1,364.41

60605 $1,636.55

60650 $1,200.97

61000 $109.08

61001 $103.90

61020 $102.79

61026 $107.23

61050 $87.26

61055 $123.87

61070 $57.31

61105 $452.21

61107 $301.35

61108 $877.81

61120 $728.42

61140 $1,230.55

61150 $1,309.68

137 of 300


ND Medicaid


as of 7/1/2020



61151 $964.33

61154 $1,237.58

61156 $1,203.19

61210 $353.12

61215 $498.43

61250 $843.42

61253 $964.33

61304 $1,592.18

61305 $1,941.23

61312 $2,006.31

61313 $1,920.52

61314 $1,770.40

61315 $1,999.28

61316 $84.30

61320 $1,837.70

61321 $2,056.59

61322 $2,300.63

61323 $2,312.10

61330 $1,736.38

61333 $1,953.06

61340 $1,396.58

61343 $2,125.00

61345 $1,973.77

61450 $1,856.55

61458 $1,946.04

61460 $2,035.89

61500 $1,296.37

61501 $1,131.09

61510 $2,126.11

61512 $2,468.13

61514 $1,849.16

61516 $1,811.81

61517 $83.94

61518 $2,674.83

61519 $2,851.57

138 of 300


ND Medicaid


as of 7/1/2020



61520 $3,643.60

61521 $3,073.43

61522 $2,114.65

61524 $2,014.07

61526 $3,313.03

61530 $2,969.90

61531 $1,187.29

61533 $1,478.29

61534 $1,596.25

61535 $973.94

61536 $2,490.69

61537 $2,379.39

61538 $2,571.67

61539 $2,281.04

61540 $2,106.88

61541 $2,078.04

61543 $2,100.60

61544 $1,836.59

61545 $3,080.08

61546 $2,229.64

61548 $1,532.28

61550 $1,157.34

61552 $1,437.99

61556 $1,652.08

61557 $1,631.37

61558 $1,819.21

61559 $2,317.64

61563 $1,916.46

61564 $2,325.78

61566 $2,169.00

61567 $2,471.46

61570 $1,808.86

61571 $1,924.96

61575 $2,420.07

61576 $4,087.30

139 of 300


ND Medicaid


as of 7/1/2020



61580 $2,482.92

61581 $2,731.03

61582 $3,032.39

61583 $2,829.39

61584 $2,813.12

61585 $3,174.00

61586 $2,440.40

61590 $3,076.02

61591 $3,094.13

61592 $3,110.03

61595 $2,379.02

61596 $2,488.84

61597 $2,871.91

61598 $2,789.45

61600 $2,152.36

61601 $2,372.37

61605 $2,207.09

61606 $2,885.22

61607 $2,674.09

61608 $3,177.33

61611 $449.26

61613 $3,204.32

61615 $2,752.85

61616 $3,265.33

61618 $1,258.29

61619 $1,405.82

61623 $563.14

61624 $1,134.42

61626 $890.38

61630 $1,348.51

61635 $1,443.54

61640 $485.86

61641 $170.83

61642 $341.29

61645 $830.11

140 of 300


ND Medicaid


as of 7/1/2020



61650 $561.29

61651 $240.34

61680 $2,181.94

61682 $4,073.99

61684 $2,746.93

61686 $4,404.19

61690 $2,109.84

61692 $3,528.97

61697 $4,075.84

61698 $4,532.49

61700 $3,293.80

61702 $3,890.22

61703 $1,317.08

61705 $2,513.61

61708 $2,458.89

61710 $2,075.08

61711 $2,508.44

61720 $1,231.66

61735 $1,542.26

61750 $1,364.04

61751 $1,339.63

61760 $1,530.06

61770 $1,569.25

61781 $226.29

61782 $176.37

61783 $226.29

61790 $855.99

61791 $1,092.27

61796 $984.30

61797 $210.76

61798 $1,336.31

61799 $291.00

61800 $147.16

61850 $955.45

61860 $1,513.05

141 of 300


ND Medicaid


as of 7/1/2020



61863 $1,457.59

61864 $271.77

61867 $2,204.50

61868 $478.84

61870 $1,148.47

61880 $566.10

61885 $511.75

61886 $843.79

61888 $386.40

62000 $1,002.41

62005 $1,232.03

62010 $1,486.80

62100 $1,548.18

62115 $1,628.78

62117 $1,899.08

62120 $2,068.80

62121 $1,566.29

62140 $1,005.74

62141 $1,116.30

62142 $865.97

62143 $1,013.88

62145 $1,379.94

62146 $1,124.43

62147 $1,389.55

62148 $121.65

62160 $181.55

62161 $1,467.57

62162 $1,827.71

62163 $1,190.99

62164 $2,025.16

62165 $1,504.55

62180 $1,548.18

62190 $901.10

62192 $956.93

62194 $479.21

142 of 300


ND Medicaid


as of 7/1/2020



62200 $1,332.98

62201 $1,175.09

62220 $963.59

62223 $1,018.68

62225 $518.03

62230 $821.23

62252 $80.98

62252 26 $44.74

62252 TC $36.24

62256 $590.87

62258 $1,081.91

62263 $638.20

62264 $454.80

62267 $275.84

62268 $265.49

62269 $275.10

62270 $143.84

62272 $187.10

62273 $177.48

62280 $364.21

62281 $247.74

62282 $319.84

62284 $205.96

62287 $597.90

62290 $367.54

62291 $347.94

62292 $598.64

62294 $921.81

62302 $268.81

62303 $273.99

62304 $265.12

62305 $288.78

62320 $169.35

62321 $269.18

62322 $154.93

143 of 300


ND Medicaid


as of 7/1/2020



62323 $266.23

62324 $147.16

62325 $252.91

62326 $151.60

62327 $258.09

62328 $269.18

62329 $331.67

62350 $401.93

62351 $864.12

62355 $273.25

62360 $316.88

62361 $420.41

62362 $385.66

62365 $296.55

62367 $32.91

62368 $45.85

62369 $99.10

62370 $102.79

63001 $1,209.48

63003 $1,213.18

63005 $1,172.50

63011 $1,087.09

63012 $1,176.94

63015 $1,447.23

63016 $1,491.60

63017 $1,234.25

63020 $1,145.14

63030 $964.70

63035 $188.21

63040 $1,376.24

63042 $1,288.98

63045 $1,264.20

63046 $1,212.07

63047 $1,093.74

63048 $207.80

144 of 300


ND Medicaid


as of 7/1/2020



63050 $1,486.43

63051 $1,689.42

63055 $1,590.33

63056 $1,469.05

63057 $314.29

63064 $1,744.52

63066 $197.82

63075 $1,336.68

63076 $241.82

63077 $1,494.19

63078 $198.93

63081 $1,735.64

63082 $261.05

63085 $1,899.45

63086 $187.84

63087 $2,376.06

63088 $252.54

63090 $1,958.24

63091 $177.48

63101 $2,278.45

63102 $2,239.99

63103 $288.41

63170 $1,543.00

63172 $1,352.94

63173 $1,670.20

63180 $1,440.95

63182 $1,579.98

63185 $1,140.33

63190 $1,260.87

63191 $1,337.78

63194 $1,547.81

63195 $1,484.21

63196 $1,722.70

63197 $1,656.15

63198 $2,021.10

145 of 300


ND Medicaid


as of 7/1/2020



63199 $2,116.86

63200 $1,489.39

63250 $2,865.62

63251 $2,930.33

63252 $2,929.59

63265 $1,629.15

63266 $1,678.70

63267 $1,349.99

63268 $1,388.07

63270 $2,008.53

63271 $2,007.79

63272 $1,844.35

63273 $1,806.27

63275 $1,755.98

63276 $1,743.04

63277 $1,530.06

63278 $1,542.26

63280 $2,052.53

63281 $2,029.97

63282 $1,916.83

63283 $1,840.66

63285 $2,527.30

63286 $2,499.19

63287 $2,651.16

63290 $2,696.65

63295 $317.62

63300 $1,796.28

63301 $2,132.76

63302 $2,107.62

63303 $2,236.67

63304 $2,271.42

63305 $2,417.11

63306 $2,375.33

63307 $2,325.41

63308 $314.29

146 of 300


ND Medicaid


as of 7/1/2020



63600 $1,057.88

63610 $558.33

63620 $1,085.61

63621 $242.19

63650 $1,988.56

63655 $821.97

63661 $661.13

63662 $831.59

63663 $881.50

63664 $864.12

63685 $363.84

63688 $374.20

63700 $1,268.27

63702 $1,385.85

63704 $1,609.19

63706 $1,787.41

63707 $919.22

63709 $1,097.81

63710 $1,078.58

63740 $952.87

63741 $666.30

63744 $667.78

63746 $591.61

64400 $109.45

64405 $72.47

64408 $70.99

64415 $116.84

64416 $66.19

64417 $141.62

64418 $87.26

64420 $103.16

64421 $34.76

64425 $115.73

64430 $92.81

64435 $75.06

147 of 300


ND Medicaid


as of 7/1/2020



64445 $130.15

64446 $61.01

64447 $91.70

64448 $63.23

64449 $63.97

64450 $78.76

64451 $218.53

64454 $220.75

64455 $49.92

64461 $136.07

64462 $76.17

64463 $207.80

64479 $264.38

64480 $131.26

64483 $245.52

64484 $107.60

64486 $114.99

64487 $188.58

64488 $141.62

64489 $292.85

64490 $197.08

64491 $98.36

64492 $99.10

64493 $179.70

64494 $91.70

64495 $91.70

64505 $128.68

64510 $143.84

64517 $198.56

64520 $222.59

64530 $223.70

64553 $2,109.10

64555 $1,953.80

64561 $777.23

64566 $130.89

148 of 300


ND Medicaid


as of 7/1/2020



64568 $623.41

64569 $748.02

64570 $715.48

64575 $342.03

64580 $312.08

64581 $678.88

64585 $255.50

64590 $273.62

64595 $246.63

64600 $458.13

64605 $638.57

64610 $783.15

64611 $121.65

64612 $136.07

64615 $148.64

64616 $132.00

64617 $166.02

64620 $215.20

64624 $423.37

64625 $516.92

64630 $248.85

64632 $90.59

64633 $434.47

64634 $195.23

64635 $430.03

64636 $177.85

64640 $257.35

64642 $148.27

64643 $93.92

64644 $173.79

64645 $118.69

64646 $155.30

64647 $177.48

64650 $82.83

64653 $99.46

149 of 300


ND Medicaid


as of 7/1/2020



64680 $348.31

64681 $579.41

64702 $515.81

64704 $332.41

64708 $513.96

64712 $596.79

64713 $789.43

64714 $742.47

64716 $525.80

64718 $606.77

64719 $411.54

64721 $445.56

64722 $366.43

64726 $278.43

64727 $183.03

64732 $437.42

64734 $494.00

64736 $361.62

64738 $469.59

64740 $488.45

64742 $509.90

64744 $488.08

64746 $431.88

64755 $922.18

64760 $520.25

64763 $514.70

64766 $634.87

64771 $620.82

64772 $573.12

64774 $418.57

64776 $399.71

64778 $183.77

64782 $468.11

64783 $219.27

64784 $742.47

150 of 300


ND Medicaid


as of 7/1/2020



64786 $1,005.37

64787 $244.41

64788 $408.95

64790 $838.98

64792 $1,060.10

64795 $191.16

64802 $816.06

64804 $1,151.80

64809 $1,054.92

64818 $790.54

64820 $744.69

64821 $706.24

64822 $706.24

64823 $801.27

64831 $703.28

64832 $340.55

64834 $753.94

64835 $827.52

64836 $827.52

64837 $369.76

64840 $975.05

64856 $1,027.56

64857 $1,071.56

64858 $1,190.99

64859 $251.07

64861 $1,470.53

64862 $1,392.14

64864 $879.65

64865 $1,115.19

64866 $1,301.92

64868 $1,021.27

64872 $117.58

64874 $175.64

64876 $198.93

64885 $1,128.50

151 of 300


ND Medicaid


as of 7/1/2020



64886 $1,301.92

64890 $1,093.74

64891 $1,163.26

64892 $1,063.79

64893 $1,134.79

64895 $1,342.96

64896 $1,447.97

64897 $1,283.06

64898 $1,389.55

64901 $602.34

64902 $697.73

64905 $1,036.43

64907 $1,317.82

64910 $806.44

64911 $1,040.87

64912 $922.18

64913 $181.55

65091 $711.41

65093 $704.39

65101 $819.38

65103 $849.70

65105 $930.68

65110 $1,310.05

65112 $1,509.72

65114 $1,579.24

65125 $474.40

65130 $815.32

65135 $826.04

65140 $892.60

65150 $658.17

65155 $932.16

65175 $738.78

65205 $38.82

65210 $47.33

65220 $61.01

152 of 300


ND Medicaid


as of 7/1/2020



65222 $70.25

65235 $739.52

65260 $1,000.20

65265 $1,122.96

65270 $291.00

65272 $536.89

65273 $391.94

65275 $603.08

65280 $690.34

65285 $1,139.96

65286 $728.05

65290 $504.72

65400 $706.98

65410 $148.64

65420 $549.09

65426 $687.38

65430 $119.06

65435 $84.67

65436 $398.60

65450 $336.48

65600 $427.44

65710 $1,157.71

65730 $1,279.36

65750 $1,286.02

65755 $1,280.10

65756 $1,212.81

65770 $1,435.77

65772 $466.26

65775 $579.41

65778 $1,470.53

65779 $1,269.75

65780 $685.90

65781 $1,367.73

65782 $1,180.64

65785 $2,486.25

153 of 300


ND Medicaid


as of 7/1/2020



65800 $123.13

65810 $477.36

65815 $665.19

65820 $809.03

65850 $865.97

65855 $254.02

65860 $319.10

65865 $489.19

65870 $609.73

65875 $650.03

65880 $683.68

65900 $1,008.70

65920 $813.10

65930 $657.80

66020 $200.78

66030 $179.70

66130 $726.20

66150 $902.58

66155 $901.84

66160 $1,015.36

66170 $1,124.43

66172 $1,225.38

66174 $971.72

66175 $1,017.57

66179 $1,108.90

66180 $1,170.28

66183 $1,058.25

66184 $809.40

66185 $870.78

66225 $958.78

66250 $779.82

66500 $385.29

66505 $420.41

66600 $895.55

66605 $1,109.27

154 of 300


ND Medicaid


as of 7/1/2020



66625 $440.75

66630 $583.48

66635 $588.65

66680 $533.93

66682 $695.15

66700 $466.26

66710 $457.02

66711 $518.03

66720 $477.36

66740 $452.95

66761 $309.49

66762 $491.78

66770 $546.13

66820 $444.82

66821 $342.77

66825 $819.38

66830 $729.53

66840 $713.63

66850 $812.36

66852 $865.23

66920 $772.42

66930 $880.39

66940 $804.59

66982 $769.47

66984 $561.29

66985 $789.43

66986 $931.05

66990 $92.07

67005 $485.49

67010 $556.49

67015 $609.36

67025 $761.33

67027 $873.74

67028 $103.53

67030 $559.81

155 of 300


ND Medicaid


as of 7/1/2020



67031 $403.04

67036 $923.66

67039 $988.73

67040 $1,068.23

67041 $1,179.90

67042 $1,179.53

67043 $1,244.98

67101 $342.03

67105 $305.79

67107 $1,159.56

67108 $1,228.34

67110 $913.67

67113 $1,372.54

67115 $512.48

67120 $688.49

67121 $930.68

67141 $540.22

67145 $543.54

67208 $617.87

67210 $532.45

67218 $1,428.74

67220 $548.72

67221 $289.15

67225 $30.32

67227 $302.83

67228 $351.64

67229 $1,195.06

67250 $867.82

67255 $703.65

67311 $613.80

67312 $736.93

67314 $696.99

67316 $826.41

67318 $728.05

67320 $328.71

156 of 300


ND Medicaid


as of 7/1/2020



67331 $312.45

67332 $338.33

67334 $307.64

67335 $150.86

67340 $365.69

67343 $675.55

67345 $248.11

67346 $197.45

67400 $1,014.25

67405 $870.78

67412 $949.91

67413 $937.71

67414 $1,434.66

67415 $106.86

67420 $1,724.18

67430 $1,358.12

67440 $1,315.97

67445 $1,511.57

67450 $1,365.52

67500 $74.69

67505 $85.04

67515 $65.82

67550 $1,054.92

67560 $1,080.43

67570 $1,277.14

67700 $290.63

67710 $245.15

67715 $263.27

67800 $132.37

67801 $167.87

67805 $208.54

67808 $377.89

67810 $187.47

67820 $27.36

67825 $137.18

157 of 300


ND Medicaid


as of 7/1/2020



67830 $279.17

67835 $451.47

67840 $289.52

67850 $223.70

67875 $183.03

67880 $477.73

67882 $586.44

67900 $665.19

67901 $806.44

67902 $742.84

67903 $618.61

67904 $761.70

67906 $520.25

67908 $532.82

67909 $561.29

67911 $575.34

67912 $938.08

67914 $499.17

67915 $317.25

67916 $626.00

67917 $637.83

67921 $489.56

67922 $308.75

67923 $626.37

67924 $666.67

67930 $381.22

67935 $615.28

67938 $270.29

67950 $597.90

67961 $600.86

67966 $798.31

67971 $741.00

67973 $953.24

67974 $951.76

67975 $701.80

158 of 300


ND Medicaid


as of 7/1/2020



68020 $124.24

68040 $64.71

68100 $184.88

68110 $242.56

68115 $336.48

68130 $566.10

68135 $162.32

68200 $42.89

68320 $762.07

68325 $674.44

68326 $661.87

68328 $725.83

68330 $637.09

68335 $664.09

68340 $600.86

68360 $556.86

68362 $672.96

68371 $424.11

68400 $304.31

68420 $342.03

68440 $106.12

68500 $1,042.72

68505 $1,037.91

68510 $469.59

68520 $729.53

68525 $268.81

68530 $448.89

68540 $981.71

68550 $1,211.70

68700 $619.71

68705 $262.90

68720 $803.11

68745 $807.18

68750 $841.57

68760 $221.85

159 of 300


ND Medicaid


as of 7/1/2020



68761 $153.45

68770 $644.86

68801 $95.03

68810 $164.54

68811 $138.66

68815 $404.15

68816 $820.12

68840 $134.96

68850 $65.08

69000 $193.01

69005 $222.59

69020 $238.12

69100 $101.31

69105 $145.68

69110 $476.99

69120 $401.93

69140 $898.14

69145 $411.91

69150 $1,043.83

69155 $1,664.28

69200 $83.20

69205 $99.46

69209 $14.42

69210 $48.44

69220 $80.98

69222 $218.53

69300 $635.98

69310 $1,116.67

69320 $1,562.60

69420 $192.64

69421 $150.86

69424 $131.63

69433 $203.74

69436 $160.47

69440 $701.43

160 of 300


ND Medicaid


as of 7/1/2020



69450 $555.38

69501 $730.27

69502 $969.51

69505 $1,230.92

69511 $1,260.51

69530 $1,685.36

69535 $2,694.43

69540 $212.24

69550 $1,064.53

69552 $1,598.46

69554 $2,553.55

69601 $1,044.94

69602 $1,106.32

69603 $1,287.87

69604 $1,130.35

69605 $1,591.44

69610 $385.66

69620 $725.83

69631 $901.47

69632 $1,096.70

69633 $1,063.05

69635 $1,260.51

69636 $1,411.37

69637 $1,405.08

69641 $1,058.99

69642 $1,359.23

69643 $1,242.02

69644 $1,509.35

69645 $1,484.95

69646 $1,572.95

69650 $816.43

69660 $939.92

69661 $1,226.49

69662 $1,169.54

69666 $823.45

161 of 300


ND Medicaid


as of 7/1/2020



69667 $822.34

69670 $961.00

69676 $846.01

69700 $684.42

69711 $860.80

69714 $1,076.00

69715 $1,329.28

69717 $1,128.87

69718 $1,342.96

69720 $1,206.15

69725 $1,901.67

69740 $1,181.38

69745 $1,259.03

69801 $218.53

69805 $1,054.18

69806 $945.47

69905 $932.90

69910 $1,016.46

69915 $1,539.67

69930 $1,238.69

69950 $1,785.56

69955 $2,000.76

69960 $1,927.55

69970 $2,165.67

69990 $209.28

70010 $61.75

70015 $168.61

70015 26 $61.38

70015 TC $107.23

70030 $32.17

70030 26 $8.87

70030 TC $23.29

70100 $38.09

70100 26 $9.61

70100 TC $28.47

162 of 300


ND Medicaid


as of 7/1/2020



70110 $44.00

70110 26 $13.31

70110 TC $30.69

70120 $38.09

70120 26 $9.61

70120 TC $28.47

70130 $61.38

70130 26 $17.75

70130 TC $43.63

70134 $58.79

70134 26 $18.49

70134 TC $40.30

70140 $32.54

70140 26 $10.72

70140 TC $21.82

70150 $47.70

70150 26 $14.05

70150 TC $33.65

70160 $37.72

70160 26 $9.24

70160 TC $28.47

70170 26 $15.16

70190 $39.93

70190 26 $11.83

70190 TC $28.10

70200 $48.44

70200 26 $14.79

70200 TC $33.65

70210 $32.17

70210 26 $9.24

70210 TC $22.92

70220 $38.09

70220 26 $11.83

70220 TC $26.25

70240 $34.76

163 of 300


ND Medicaid


as of 7/1/2020



70240 26 $10.35

70240 TC $24.40

70250 $36.98

70250 26 $10.72

70250 TC $26.25

70260 $45.85

70260 26 $15.16

70260 TC $30.69

70300 $14.42

70300 26 $5.92

70300 TC $8.50

70310 $40.67

70310 26 $8.13

70310 TC $32.54

70320 $57.68

70320 26 $12.20

70320 TC $45.48

70328 $34.76

70328 26 $9.61

70328 TC $25.14

70330 $53.61

70330 26 $12.94

70330 TC $40.67

70332 $84.30

70332 26 $28.10

70332 TC $56.20

70336 $319.10

70336 26 $76.17

70336 TC $242.93

70350 $18.12

70350 26 $9.61

70350 TC $8.50

70355 $19.97

70355 26 $11.09

70355 TC $8.87

164 of 300


ND Medicaid


as of 7/1/2020



70360 $31.80

70360 26 $9.61

70360 TC $22.19

70370 $92.07

70370 26 $15.53

70370 TC $76.54

70371 $110.56

70371 26 $43.63

70371 TC $66.93

70380 $37.35

70380 26 $8.87

70380 TC $28.47

70390 $116.10

70390 26 $19.60

70390 TC $96.51

70450 $119.43

70450 26 $44.00

70450 TC $75.43

70460 $168.98

70460 26 $58.42

70460 TC $110.56

70470 $197.45

70470 26 $65.45

70470 TC $132.00

70480 $207.06

70480 26 $65.82

70480 TC $141.25

70481 $231.84

70481 26 $58.42

70481 TC $173.42

70482 $256.24

70482 26 $65.08

70482 TC $191.16

70486 $144.21

70486 26 $44.37

165 of 300


ND Medicaid


as of 7/1/2020



70486 TC $99.83

70487 $173.05

70487 26 $58.42

70487 TC $114.62

70488 $210.39

70488 26 $65.45

70488 TC $144.95

70490 $169.72

70490 26 $66.19

70490 TC $103.53

70491 $209.28

70491 26 $71.36

70491 TC $137.92

70492 $253.28

70492 26 $83.94

70492 TC $169.35

70496 $306.53

70496 26 $89.85

70496 TC $216.68

70498 $306.16

70498 26 $89.85

70498 TC $216.31

70540 $269.92

70540 26 $69.14

70540 TC $200.78

70542 $320.21

70542 26 $83.57

70542 TC $236.65

70543 $403.04

70543 26 $110.19

70543 TC $292.85

70544 $253.65

70544 26 $61.75

70544 TC $191.90

70545 $265.12

166 of 300


ND Medicaid


as of 7/1/2020



70545 26 $61.75

70545 TC $203.37

70546 $384.55

70546 26 $76.54

70546 TC $308.01

70547 $254.76

70547 26 $62.12

70547 TC $192.64

70548 $284.34

70548 26 $77.28

70548 TC $207.06

70549 $403.78

70549 26 $93.18

70549 TC $310.60

70551 $230.36

70551 26 $76.54

70551 TC $153.82

70552 $319.10

70552 26 $91.70

70552 TC $227.40

70553 $377.15

70553 26 $117.95

70553 TC $259.20

70554 $447.78

70554 26 $109.08

70554 TC $338.70

70555 26 $129.79

70557 26 $160.11

70558 26 $177.48

70559 26 $167.87

71045 $26.62

71045 26 $9.61

71045 TC $17.01

71046 $34.02

71046 26 $11.46

167 of 300


ND Medicaid


as of 7/1/2020



71046 TC $22.56

71047 $42.89

71047 26 $14.42

71047 TC $28.47

71048 $46.59

71048 26 $17.01

71048 TC $29.58

71100 $36.98

71100 26 $11.83

71100 TC $25.14

71101 $42.52

71101 26 $14.05

71101 TC $28.47

71110 $44.74

71110 26 $15.53

71110 TC $29.21

71111 $53.25

71111 26 $17.01

71111 TC $36.24

71120 $34.02

71120 26 $10.72

71120 TC $23.29

71130 $41.41

71130 26 $11.83

71130 TC $29.58

71250 $163.80

71250 26 $59.90

71250 TC $103.90

71260 $202.63

71260 26 $64.34

71260 TC $138.29

71270 $239.97

71270 26 $70.99

71270 TC $168.98

71275 $313.19

168 of 300


ND Medicaid


as of 7/1/2020



71275 26 $93.55

71275 TC $219.64

71550 $410.80

71550 26 $75.43

71550 TC $335.37

71551 $452.95

71551 26 $88.74

71551 TC $364.21

71552 $574.23

71552 26 $116.10

71552 TC $458.13

71555 $397.86

71555 26 $92.44

71555 TC $305.42

72020 $25.14

72020 26 $8.50

72020 TC $16.64

72040 $39.56

72040 26 $11.83

72040 TC $27.73

72050 $52.51

72050 26 $14.42

72050 TC $38.09

72052 $61.75

72052 26 $15.90

72052 TC $45.85

72070 $32.91

72070 26 $10.72

72070 TC $22.19

72072 $39.93

72072 26 $12.20

72072 TC $27.73

72074 $44.74

72074 26 $12.94

72074 TC $31.80

169 of 300


ND Medicaid


as of 7/1/2020



72080 $35.50

72080 26 $11.46

72080 TC $24.03

72081 $43.26

72081 26 $14.05

72081 TC $29.21

72082 $69.51

72082 26 $16.64

72082 TC $52.88

72083 $80.98

72083 26 $18.86

72083 TC $62.12

72084 $96.14

72084 26 $21.45

72084 TC $74.69

72100 $39.56

72100 26 $11.83

72100 TC $27.73

72110 $50.29

72110 26 $13.68

72110 TC $36.61

72114 $61.75

72114 26 $15.90

72114 TC $45.85

72120 $41.04

72120 26 $11.83

72120 TC $29.21

72125 $161.21

72125 26 $51.77

72125 TC $109.45

72126 $201.89

72126 26 $62.86

72126 TC $139.03

72127 $238.12

72127 26 $65.45

170 of 300


ND Medicaid


as of 7/1/2020



72127 TC $172.68

72128 $161.21

72128 26 $51.77

72128 TC $109.45

72129 $203.37

72129 26 $62.86

72129 TC $140.51

72130 $238.49

72130 26 $65.45

72130 TC $173.05

72131 $160.47

72131 26 $51.77

72131 TC $108.71

72132 $202.26

72132 26 $62.86

72132 TC $139.40

72133 $237.01

72133 26 $65.08

72133 TC $171.94

72141 $224.07

72141 26 $76.54

72141 TC $147.53

72142 $326.13

72142 26 $92.07

72142 TC $234.06

72146 $224.07

72146 26 $76.54

72146 TC $147.53

72147 $323.91

72147 26 $91.70

72147 TC $232.21

72148 $224.44

72148 26 $76.54

72148 TC $147.90

72149 $320.95

171 of 300


ND Medicaid


as of 7/1/2020



72149 26 $91.70

72149 TC $229.25

72156 $380.11

72156 26 $117.95

72156 TC $262.16

72157 $380.85

72157 26 $117.95

72157 TC $262.90

72158 $379.37

72158 26 $117.95

72158 TC $261.42

72159 $413.02

72159 26 $93.18

72159 TC $319.84

72170 $29.58

72170 26 $9.24

72170 TC $20.34

72190 $42.15

72190 26 $13.31

72190 TC $28.84

72191 $333.52

72191 26 $92.07

72191 TC $241.45

72192 $150.49

72192 26 $56.20

72192 TC $94.29

72193 $251.07

72193 26 $59.90

72193 TC $191.16

72194 $281.76

72194 26 $62.86

72194 TC $218.90

72195 $275.10

72195 26 $75.43

72195 TC $199.67

172 of 300


ND Medicaid


as of 7/1/2020



72196 $320.95

72196 26 $89.11

72196 TC $231.84

72197 $404.15

72197 26 $112.78

72197 TC $291.37

72198 $399.71

72198 26 $91.70

72198 TC $308.01

72200 $33.28

72200 26 $9.24

72200 TC $24.03

72202 $39.56

72202 26 $12.20

72202 TC $27.36

72220 $32.54

72220 26 $9.24

72220 TC $23.29

72240 $115.36

72240 26 $47.33

72240 TC $68.04

72255 $116.10

72255 26 $48.44

72255 TC $67.67

72265 $106.49

72265 26 $42.15

72265 TC $64.34

72270 $146.42

72270 26 $69.51

72270 TC $76.91

72275 $135.70

72275 26 $40.67

72275 TC $95.03

72285 $126.09

72285 26 $61.01

173 of 300


ND Medicaid


as of 7/1/2020



72285 TC $65.08

72295 $110.93

72295 26 $44.00

72295 TC $66.93

73000 $32.54

73000 26 $8.87

73000 TC $23.66

73010 $28.84

73010 26 $9.61

73010 TC $19.23

73020 $22.19

73020 26 $8.13

73020 TC $14.05

73030 $34.39

73030 26 $9.98

73030 TC $24.40

73040 $124.98

73040 26 $28.47

73040 TC $96.51

73050 $32.54

73050 26 $9.98

73050 TC $22.56

73060 $32.54

73060 26 $8.87

73060 TC $23.66

73070 $29.58

73070 26 $8.87

73070 TC $20.71

73080 $32.17

73080 26 $9.24

73080 TC $22.92

73085 $116.84

73085 26 $29.95

73085 TC $86.89

73090 $29.95

174 of 300


ND Medicaid


as of 7/1/2020



73090 26 $8.87

73090 TC $21.08

73092 $31.43

73092 26 $8.50

73092 TC $22.92

73100 $34.02

73100 26 $8.87

73100 TC $25.14

73110 $40.30

73110 26 $9.24

73110 TC $31.06

73115 $131.26

73115 26 $29.21

73115 TC $102.05

73120 $31.43

73120 26 $8.87

73120 TC $22.56

73130 $36.24

73130 26 $9.24

73130 TC $26.99

73140 $36.98

73140 26 $7.40

73140 TC $29.58

73200 $185.25

73200 26 $51.77

73200 TC $133.48

73201 $230.73

73201 26 $59.90

73201 TC $170.83

73202 $287.67

73202 26 $62.86

73202 TC $224.81

73206 $339.81

73206 26 $92.44

73206 TC $247.37

175 of 300


ND Medicaid


as of 7/1/2020



73218 $365.69

73218 26 $69.88

73218 TC $295.81

73219 $403.78

73219 26 $83.94

73219 TC $319.84

73220 $496.58

73220 26 $110.93

73220 TC $385.66

73221 $237.38

73221 26 $70.62

73221 TC $166.76

73222 $378.26

73222 26 $83.94

73222 TC $294.33

73223 $468.11

73223 26 $110.56

73223 TC $357.56

73225 $409.69

73225 26 $89.85

73225 TC $319.84

73501 $32.91

73501 26 $9.98

73501 TC $22.92

73502 $46.96

73502 26 $11.83

73502 TC $35.13

73503 $58.05

73503 26 $14.42

73503 TC $43.63

73521 $41.41

73521 26 $11.83

73521 TC $29.58

73522 $53.98

73522 26 $15.53

176 of 300


ND Medicaid


as of 7/1/2020



73522 TC $38.45

73523 $61.38

73523 26 $16.64

73523 TC $44.74

73525 $127.57

73525 26 $30.32

73525 TC $97.25

73551 $30.32

73551 26 $8.87

73551 TC $21.45

73552 $35.87

73552 26 $9.61

73552 TC $26.25

73560 $34.76

73560 26 $8.87

73560 TC $25.88

73562 $40.67

73562 26 $9.98

73562 TC $30.69

73564 $45.48

73564 26 $11.83

73564 TC $33.65

73565 $40.30

73565 26 $9.24

73565 TC $31.06

73580 $141.25

73580 26 $29.58

73580 TC $111.67

73590 $31.80

73590 26 $8.50

73590 TC $23.29

73592 $31.43

73592 26 $8.50

73592 TC $22.92

73600 $32.91

177 of 300


ND Medicaid


as of 7/1/2020



73600 26 $8.87

73600 TC $24.03

73610 $36.24

73610 26 $9.24

73610 TC $26.99

73615 $132.74

73615 26 $29.95

73615 TC $102.79

73620 $28.84

73620 26 $8.13

73620 TC $20.71

73630 $34.02

73630 26 $8.87

73630 TC $25.14

73650 $29.21

73650 26 $8.50

73650 TC $20.71

73660 $29.21

73660 26 $7.03

73660 TC $22.19

73700 $160.47

73700 26 $51.77

73700 TC $108.71

73701 $200.78

73701 26 $59.90

73701 TC $140.88

73702 $241.08

73702 26 $62.49

73702 TC $178.59

73706 $367.91

73706 26 $96.88

73706 TC $271.03

73718 $266.60

73718 26 $69.51

73718 TC $197.08

178 of 300


ND Medicaid


as of 7/1/2020



73719 $315.03

73719 26 $83.57

73719 TC $231.47

73720 $403.78

73720 26 $110.19

73720 TC $293.59

73721 $236.65

73721 26 $69.88

73721 TC $166.76

73722 $379.00

73722 26 $83.94

73722 TC $295.07

73723 $467.37

73723 26 $110.56

73723 TC $356.82

73725 $400.45

73725 26 $92.81

73725 TC $307.64

74018 $30.32

74018 26 $9.61

74018 TC $20.71

74019 $37.35

74019 26 $12.20

74019 TC $25.14

74021 $43.26

74021 26 $14.05

74021 TC $29.21

74022 $50.29

74022 26 $16.64

74022 TC $33.65

74150 $153.82

74150 26 $61.38

74150 TC $92.44

74160 $255.87

74160 26 $65.82

179 of 300


ND Medicaid


as of 7/1/2020



74160 TC $190.06

74170 $288.41

74170 26 $72.10

74170 TC $216.31

74174 $419.31

74174 26 $112.78

74174 TC $306.53

74175 $334.26

74175 26 $93.18

74175 TC $241.08

74176 $206.69

74176 26 $89.85

74176 TC $116.84

74177 $338.33

74177 26 $93.92

74177 TC $244.41

74178 $380.48

74178 26 $103.16

74178 TC $277.32

74181 $232.58

74181 26 $75.43

74181 TC $157.15

74182 $363.84

74182 26 $89.11

74182 TC $274.73

74183 $404.89

74183 26 $112.78

74183 TC $292.11

74185 $401.56

74185 26 $92.07

74185 TC $309.49

74190 26 $23.66

74210 $97.99

74210 26 $30.69

74210 TC $67.30

180 of 300


ND Medicaid


as of 7/1/2020



74220 $99.83

74220 26 $31.06

74220 TC $68.77

74221 $112.78

74221 26 $36.24

74221 TC $76.54

74230 $133.85

74230 26 $27.36

74230 TC $106.49

74235 26 $61.38

74240 $124.61

74240 26 $41.78

74240 TC $82.83

74246 $143.47

74246 26 $46.59

74246 TC $96.88

74248 $85.04

74248 26 $35.87

74248 TC $49.18

74250 $125.35

74250 26 $42.15

74250 TC $83.20

74251 $416.72

74251 26 $60.27

74251 TC $356.45

74261 $494.37

74261 26 $123.50

74261 TC $370.87

74262 $556.12

74262 26 $128.68

74262 TC $427.44

74263 $779.82

74263 26 $118.32

74263 TC $661.50

74270 $159.74

181 of 300


ND Medicaid


as of 7/1/2020



74270 26 $53.61

74270 TC $106.12

74280 $229.25

74280 26 $64.71

74280 TC $164.54

74283 $257.35

74283 26 $107.23

74283 TC $150.12

74290 $85.41

74290 26 $16.64

74290 TC $68.77

74300 26 $18.49

74301 26 $10.72

74328 26 $36.61

74329 26 $36.61

74330 26 $46.96

74340 26 $27.73

74355 26 $39.19

74360 26 $28.47

74363 26 $44.74

74400 $132.37

74400 26 $25.14

74400 TC $107.23

74410 $134.59

74410 26 $24.77

74410 TC $109.82

74415 $157.52

74415 26 $25.14

74415 TC $132.37

74420 $76.17

74420 26 $26.25

74420 TC $49.92

74425 $134.59

74425 26 $25.88

74425 TC $108.71

182 of 300


ND Medicaid


as of 7/1/2020



74430 $41.78

74430 26 $16.64

74430 TC $25.14

74440 $95.77

74440 26 $19.23

74440 TC $76.54

74445 26 $56.94

74450 26 $16.64

74455 $101.31

74455 26 $17.01

74455 TC $84.30

74470 26 $26.99

74485 $117.58

74485 26 $41.78

74485 TC $75.80

74710 $40.67

74710 26 $17.75

74710 TC $22.92

74712 $489.56

74712 26 $154.19

74712 TC $335.37

74713 $237.38

74713 26 $95.77

74713 TC $141.62

74740 $93.18

74740 26 $19.60

74740 TC $73.58

74742 26 $31.43

74775 26 $31.80

75557 $331.67

75557 26 $119.80

75557 TC $211.87

75559 $460.35

75559 26 $147.16

75559 TC $313.19

183 of 300


ND Medicaid


as of 7/1/2020



75561 $434.84

75561 26 $131.63

75561 TC $303.20

75563 $515.07

75563 26 $151.97

75563 TC $363.10

75565 $54.35

75565 26 $12.57

75565 TC $41.78

75571 $108.71

75571 26 $29.95

75571 TC $78.76

75572 $257.35

75572 26 $89.48

75572 TC $167.87

75573 $346.46

75573 26 $130.89

75573 TC $215.57

75574 $372.72

75574 26 $122.39

75574 TC $250.33

75600 $207.06

75600 26 $24.77

75600 TC $182.29

75605 $134.22

75605 26 $56.20

75605 TC $78.02

75625 $141.25

75625 26 $70.25

75625 TC $70.99

75630 $174.53

75630 26 $99.10

75630 TC $75.43

75635 $459.61

75635 26 $122.02

184 of 300


ND Medicaid


as of 7/1/2020



75635 TC $337.59

75705 $255.13

75705 26 $115.73

75705 TC $139.40

75710 $166.76

75710 26 $86.52

75710 TC $80.24

75716 $178.59

75716 26 $96.51

75716 TC $82.09

75726 $189.69

75726 26 $100.57

75726 TC $89.11

75731 $168.61

75731 26 $58.79

75731 TC $109.82

75733 $182.66

75733 26 $66.19

75733 TC $116.47

75736 $154.93

75736 26 $55.09

75736 TC $99.83

75741 $147.53

75741 26 $64.71

75741 TC $82.83

75743 $166.39

75743 26 $82.46

75743 TC $83.94

75746 $149.01

75746 26 $56.94

75746 TC $92.07

75756 $168.24

75756 26 $56.57

75756 TC $111.67

75774 $110.93

185 of 300


ND Medicaid


as of 7/1/2020



75774 26 $49.55

75774 TC $61.38

75801 26 $43.26

75803 26 $60.27

75805 26 $41.78

75807 26 $57.31

75809 $94.66

75809 26 $24.40

75809 TC $70.25

75810 26 $50.66

75820 $110.93

75820 26 $35.13

75820 TC $75.80

75822 $130.15

75822 26 $52.88

75822 TC $77.28

75825 $128.68

75825 26 $55.83

75825 TC $72.84

75827 $134.22

75827 26 $56.20

75827 TC $78.02

75831 $135.33

75831 26 $55.46

75831 TC $79.87

75833 $160.84

75833 26 $72.84

75833 TC $88.00

75840 $146.05

75840 26 $59.16

75840 TC $86.89

75842 $177.11

75842 26 $77.28

75842 TC $99.83

75860 $142.36

186 of 300


ND Medicaid


as of 7/1/2020



75860 26 $57.31

75860 TC $85.04

75870 $186.73

75870 26 $62.86

75870 TC $123.87

75872 $146.05

75872 26 $59.16

75872 TC $86.89

75880 $123.13

75880 26 $36.24

75880 TC $86.89

75885 $154.19

75885 26 $69.88

75885 TC $84.30

75887 $155.30

75887 26 $70.62

75887 TC $84.67

75889 $139.40

75889 26 $55.46

75889 TC $83.94

75891 $141.62

75891 26 $56.57

75891 TC $85.04

75893 $119.43

75893 26 $27.73

75893 TC $91.70

75894 26 $71.36

75898 26 $89.48

75901 $226.29

75901 26 $24.03

75901 TC $202.26

75902 $88.37

75902 26 $19.60

75902 TC $68.77

75956 26 $338.70

187 of 300


ND Medicaid


as of 7/1/2020



75957 26 $289.52

75958 26 $192.64

75959 26 $168.98

75970 26 $40.67

75984 $102.42

75984 26 $35.87

75984 TC $66.56

75989 $124.98

75989 26 $59.90

75989 TC $65.08

76000 $43.26

76000 26 $15.90

76000 TC $27.36

76010 $29.95

76010 26 $9.61

76010 TC $20.34

76080 $61.38

76080 26 $26.99

76080 TC $34.39

76098 $44.00

76098 26 $16.27

76098 TC $27.73

76100 $100.94

76100 26 $31.80

76100 TC $69.14

76101 $99.83

76101 26 $26.62

76101 TC $73.21

76102 $182.29

76102 26 $32.17

76102 TC $150.12

76120 $112.78

76120 26 $19.60

76120 TC $93.18

76125 26 $13.68

188 of 300


ND Medicaid


as of 7/1/2020



76376 $24.03

76376 26 $10.35

76376 TC $13.68

76377 $74.32

76377 26 $41.04

76377 TC $33.28

76380 $149.75

76380 26 $49.92

76380 TC $99.83

76390 $441.49

76390 26 $72.84

76390 TC $368.65

76391 $241.08

76391 26 $57.68

76391 TC $183.40

76506 $119.43

76506 26 $32.91

76506 TC $86.52

76510 $94.66

76510 26 $49.55

76510 TC $45.11

76511 $64.71

76511 26 $37.72

76511 TC $26.99

76512 $55.09

76512 26 $32.91

76512 TC $22.19

76513 $103.90

76513 26 $37.72

76513 TC $66.19

76514 $12.57

76514 26 $8.50

76514 TC $4.07

76516 $50.29

76516 26 $24.03

189 of 300


ND Medicaid


as of 7/1/2020



76516 TC $26.25

76519 $69.51

76519 26 $32.54

76519 TC $36.98

76529 $86.89

76529 26 $34.39

76529 TC $52.51

76536 $120.54

76536 26 $29.21

76536 TC $91.33

76604 $82.09

76604 26 $29.95

76604 TC $52.14

76641 $111.30

76641 26 $37.72

76641 TC $73.58

76642 $90.96

76642 26 $35.13

76642 TC $55.83

76700 $127.57

76700 26 $42.15

76700 TC $85.41

76705 $94.66

76705 26 $30.32

76705 TC $64.34

76706 $118.32

76706 26 $28.47

76706 TC $89.85

76770 $117.58

76770 26 $38.09

76770 TC $79.50

76775 $61.01

76775 26 $29.95

76775 TC $31.06

76776 $161.58

190 of 300


ND Medicaid


as of 7/1/2020



76776 26 $39.19

76776 TC $122.39

76800 $147.16

76800 26 $59.16

76800 TC $88.00

76801 $126.83

76801 26 $51.40

76801 TC $75.43

76802 $65.08

76802 26 $42.52

76802 TC $22.56

76805 $145.31

76805 26 $51.40

76805 TC $93.92

76810 $95.03

76810 26 $51.03

76810 TC $44.00

76811 $183.77

76811 26 $97.99

76811 TC $85.78

76812 $205.96

76812 26 $91.70

76812 TC $114.26

76813 $125.72

76813 26 $61.01

76813 TC $64.71

76814 $81.72

76814 26 $51.40

76814 TC $30.32

76815 $87.26

76815 26 $33.65

76815 TC $53.61

76816 $117.58

76816 26 $44.00

76816 TC $73.58

191 of 300


ND Medicaid


as of 7/1/2020



76817 $99.46

76817 26 $38.82

76817 TC $60.64

76818 $122.02

76818 26 $53.98

76818 TC $68.04

76819 $90.22

76819 26 $39.93

76819 TC $50.29

76820 $48.07

76820 26 $25.88

76820 TC $22.19

76821 $93.55

76821 26 $35.87

76821 TC $57.68

76825 $283.60

76825 26 $85.04

76825 TC $198.56

76826 $168.24

76826 26 $42.15

76826 TC $126.09

76827 $75.80

76827 26 $29.58

76827 TC $46.22

76828 $53.61

76828 26 $28.84

76828 TC $24.77

76830 $127.94

76830 26 $35.87

76830 TC $92.07

76831 $123.87

76831 26 $37.35

76831 TC $86.52

76856 $113.89

76856 26 $35.50

192 of 300


ND Medicaid


as of 7/1/2020



76856 TC $78.39

76857 $49.92

76857 26 $25.51

76857 TC $24.40

76870 $109.08

76870 26 $32.91

76870 TC $76.17

76872 $163.06

76872 26 $34.76

76872 TC $128.31

76873 $182.66

76873 26 $81.35

76873 TC $101.31

76881 $80.24

76881 26 $32.54

76881 TC $47.70

76882 $58.79

76882 26 $25.14

76882 TC $33.65

76885 $149.38

76885 26 $38.45

76885 TC $110.93

76886 $109.45

76886 26 $32.17

76886 TC $77.28

76932 26 $35.13

76936 $277.32

76936 26 $98.36

76936 TC $178.96

76937 $37.72

76937 26 $14.79

76937 TC $22.92

76940 26 $103.90

76941 26 $69.14

76942 $59.53

193 of 300


ND Medicaid


as of 7/1/2020



76942 26 $32.91

76942 TC $26.62

76945 26 $34.39

76946 $33.65

76946 26 $19.60

76946 TC $14.05

76948 $78.76

76948 26 $34.39

76948 TC $44.37

76965 $96.88

76965 26 $70.62

76965 TC $26.25

76970 $92.44

76970 26 $19.97

76970 TC $72.47

76975 26 $43.26

76977 $7.40

76977 26 $2.96

76977 TC $4.44

76978 $339.07

76978 26 $83.20

76978 TC $255.87

76979 $229.99

76979 26 $44.00

76979 TC $185.99

76981 $112.04

76981 26 $30.69

76981 TC $81.35

76982 $99.83

76982 26 $30.69

76982 TC $69.14

76983 $61.38

76983 26 $25.88

76983 TC $35.50

76998 26 $62.49

194 of 300


ND Medicaid


as of 7/1/2020



77001 $99.83

77001 26 $19.23

77001 TC $80.61

77002 $112.41

77002 26 $28.84

77002 TC $83.57

77003 $105.01

77003 26 $31.06

77003 TC $73.95

77011 $241.45

77011 26 $65.45

77011 TC $176.00

77012 $156.04

77012 26 $76.17

77012 TC $79.87

77013 26 $196.34

77014 $127.20

77014 26 $46.96

77014 TC $80.24

77021 $482.90

77021 26 $75.43

77021 TC $407.47

77022 26 $222.96

77046 $253.28

77046 26 $74.69

77046 TC $178.59

77047 $259.94

77047 26 $82.46

77047 TC $177.48

77048 $401.93

77048 26 $107.97

77048 TC $293.96

77049 $411.17

77049 26 $118.32

77049 TC $292.85

195 of 300


ND Medicaid


as of 7/1/2020



77053 $58.42

77053 26 $18.49

77053 TC $39.93

77054 $75.80

77054 26 $23.29

77054 TC $52.51

77063 $56.57

77063 26 $30.69

77063 TC $25.88

77065 $139.03

77065 26 $42.15

77065 TC $96.88

77066 $175.27

77066 26 $51.77

77066 TC $123.50

77067 $141.99

77067 26 $39.56

77067 TC $102.42

77071 $53.98

77072 $26.25

77072 26 $9.98

77072 TC $16.27

77073 $45.11

77073 26 $14.05

77073 TC $31.06

77074 $65.08

77074 26 $22.92

77074 TC $42.15

77075 $98.73

77075 26 $28.84

77075 TC $69.88

77076 $106.86

77076 26 $36.24

77076 TC $70.62

77077 $46.96

196 of 300


ND Medicaid


as of 7/1/2020



77077 26 $17.75

77077 TC $29.21

77078 $119.06

77078 26 $12.94

77078 TC $106.12

77080 $41.04

77080 26 $10.35

77080 TC $30.69

77081 $33.65

77081 26 $10.72

77081 TC $22.92

77084 $384.92

77084 26 $82.83

77084 TC $302.09

77085 $55.46

77085 26 $15.53

77085 TC $39.93

77086 $35.87

77086 26 $8.87

77086 TC $26.99

77261 $73.58

77262 $111.67

77263 $174.16

77280 $289.89

77280 26 $39.19

77280 TC $250.70

77285 $484.75

77285 26 $59.90

77285 TC $424.85

77290 $519.14

77290 26 $86.15

77290 TC $432.99

77293 $470.33

77293 26 $110.56

77293 TC $359.77

197 of 300


ND Medicaid


as of 7/1/2020



77295 $506.20

77295 26 $235.17

77295 TC $271.03

77300 $68.77

77300 26 $34.02

77300 TC $34.76

77301 $1,985.97

77301 26 $437.79

77301 TC $1,548.18

77306 $154.93

77306 26 $76.91

77306 TC $78.02

77307 $300.61

77307 26 $159.37

77307 TC $141.25

77316 $226.66

77316 26 $77.28

77316 TC $149.38

77317 $296.55

77317 26 $100.94

77317 TC $195.60

77318 $424.11

77318 26 $158.63

77318 TC $265.49

77321 $98.36

77321 26 $52.88

77321 TC $45.48

77331 $67.67

77331 26 $48.07

77331 TC $19.60

77332 $48.81

77332 26 $24.77

77332 TC $24.03

77333 $125.72

77333 26 $41.41

198 of 300


ND Medicaid


as of 7/1/2020



77333 TC $84.30

77334 $132.74

77334 26 $63.60

77334 TC $69.14

77336 $82.09

77338 $505.09

77338 26 $235.17

77338 TC $269.92

77370 $127.57

77372 $1,092.63

77373 $1,257.18

77401 $25.14

77417 $11.46

77427 $196.34

77431 $109.08

77432 $438.90

77435 $662.61

77469 $328.35

77470 $138.66

77470 26 $112.04

77470 TC $26.62

77600 $484.75

77600 26 $73.95

77600 TC $410.80

77605 $880.39

77605 26 $102.79

77605 TC $777.60

77610 $711.78

77610 26 $72.10

77610 TC $639.68

77615 $1,112.23

77615 26 $101.31

77615 TC $1,010.92

77620 $633.03

77620 26 $84.30

199 of 300


ND Medicaid


as of 7/1/2020



77620 TC $548.72

77750 $398.60

77750 26 $273.99

77750 TC $124.61

77761 $419.31

77761 26 $211.13

77761 TC $208.17

77762 $555.01

77762 26 $316.51

77762 TC $238.49

77763 $783.15

77763 26 $475.51

77763 TC $307.64

77767 $249.22

77767 26 $58.05

77767 TC $191.16

77768 $373.46

77768 26 $76.91

77768 TC $296.55

77770 $349.05

77770 26 $107.23

77770 TC $241.82

77771 $623.78

77771 26 $208.54

77771 TC $415.24

77772 $939.56

77772 26 $294.70

77772 TC $644.86

77778 $899.62

77778 26 $480.32

77778 TC $419.31

77789 $132.74

77789 26 $63.23

77789 TC $69.51

77790 $15.53

200 of 300


ND Medicaid


as of 7/1/2020



78012 $85.78

78012 26 $9.98

78012 TC $75.80

78013 $202.63

78013 26 $18.86

78013 TC $183.77

78014 $252.17

78014 26 $25.14

78014 TC $227.03

78015 $236.65

78015 26 $34.39

78015 TC $202.26

78016 $298.02

78016 26 $35.87

78016 TC $262.16

78018 $330.19

78018 26 $42.89

78018 TC $287.30

78020 $86.89

78020 26 $28.84

78020 TC $58.05

78070 $312.45

78070 26 $40.30

78070 TC $272.14

78071 $372.72

78071 26 $60.64

78071 TC $312.08

78072 $469.59

78072 26 $79.50

78072 TC $390.09

78075 $472.18

78075 26 $38.09

78075 TC $434.10

78102 $178.96

78102 26 $27.36

201 of 300


ND Medicaid


as of 7/1/2020



78102 TC $151.60

78103 $227.77

78103 26 $36.24

78103 TC $191.53

78104 $262.90

78104 26 $40.30

78104 TC $222.59

78110 $73.21

78110 26 $8.50

78110 TC $64.71

78111 $77.65

78111 26 $9.98

78111 TC $67.67

78120 $75.06

78120 26 $10.35

78120 TC $64.71

78121 $82.09

78121 26 $14.42

78121 TC $67.67

78122 $101.31

78122 26 $22.19

78122 TC $79.13

78130 $132.00

78130 26 $26.99

78130 TC $105.01

78135 $295.07

78135 26 $28.10

78135 TC $266.97

78140 $117.21

78140 26 $26.99

78140 TC $90.22

78185 $179.70

78185 26 $17.75

78185 TC $161.95

78191 $132.00

202 of 300


ND Medicaid


as of 7/1/2020



78191 26 $26.99

78191 TC $105.01

78195 $373.83

78195 26 $60.27

78195 TC $313.55

78201 $200.41

78201 26 $21.82

78201 TC $178.59

78202 $215.94

78202 26 $24.77

78202 TC $191.16

78215 $205.22

78215 26 $24.77

78215 TC $180.44

78216 $134.96

78216 26 $28.10

78216 TC $106.86

78226 $345.72

78226 26 $37.72

78226 TC $308.01

78227 $466.26

78227 26 $45.85

78227 TC $420.41

78230 $183.40

78230 26 $23.29

78230 TC $160.11

78231 $110.93

78231 26 $22.92

78231 TC $88.00

78232 $108.71

78232 26 $20.71

78232 TC $88.00

78258 $227.40

78258 26 $36.24

78258 TC $191.16

203 of 300


ND Medicaid


as of 7/1/2020



78261 $215.20

78261 26 $30.32

78261 TC $184.88

78262 $252.54

78262 26 $34.76

78262 TC $217.79

78264 $350.90

78264 26 $40.30

78264 TC $310.60

78265 $414.13

78265 26 $49.55

78265 TC $364.58

78266 $453.32

78266 26 $51.03

78266 TC $402.30

78267 $11.06

78268 $94.41

78278 $367.17

78278 26 $50.66

78278 TC $316.51

78282 26 $16.64

78290 $347.94

78290 26 $34.39

78290 TC $313.55

78291 $268.44

78291 26 $44.37

78291 TC $224.07

78300 $241.82

78300 26 $32.17

78300 TC $209.65

78305 $292.85

78305 26 $42.52

78305 TC $250.33

78306 $317.25

78306 26 $44.00

204 of 300


ND Medicaid


as of 7/1/2020



78306 TC $273.25

78315 $364.95

78315 26 $52.14

78315 TC $312.82

78350 $33.65

78350 26 $11.46

78350 TC $22.19

78351 $15.90

78414 26 $22.56

78428 $195.23

78428 26 $39.19

78428 TC $156.04

78429 26 $86.52

78430 26 $82.09

78431 26 $95.40

78432 26 $101.68

78433 26 $110.93

78434 26 $32.17

78445 $205.96

78445 26 $25.88

78445 TC $180.07

78451 $354.60

78451 26 $69.51

78451 TC $285.08

78452 $494.00

78452 26 $81.72

78452 TC $412.28

78453 $318.73

78453 26 $51.40

78453 TC $267.34

78454 $457.02

78454 26 $68.77

78454 TC $388.25

78456 $325.02

78456 26 $50.29

205 of 300


ND Medicaid


as of 7/1/2020



78456 TC $274.73

78457 $184.88

78457 26 $38.82

78457 TC $146.05

78458 $216.31

78458 26 $46.96

78458 TC $169.35

78459 $1,348.64

78459 26 $78.39

78459 TC $1,271.97

78466 $210.76

78466 26 $36.61

78466 TC $174.16

78468 $202.63

78468 26 $40.30

78468 TC $162.32

78469 $235.17

78469 26 $46.96

78469 TC $188.21

78472 $239.60

78472 26 $49.92

78472 TC $189.69

78473 $303.94

78473 26 $73.58

78473 TC $230.36

78481 $184.88

78481 26 $49.92

78481 TC $134.96

78483 $253.65

78483 26 $74.32

78483 TC $179.33

78491 $1,517.17

78491 26 $76.17

78491 TC $1,442.68

78492 $1,530.34

206 of 300


ND Medicaid


as of 7/1/2020



78492 26 $89.85

78492 TC $1,442.68

78494 $237.75

78494 26 $60.27

78494 TC $177.48

78496 $44.74

78496 26 $25.14

78496 TC $19.60

78579 $197.08

78579 26 $24.77

78579 TC $172.31

78580 $249.59

78580 26 $37.72

78580 TC $211.87

78582 $351.27

78582 26 $54.35

78582 TC $296.92

78597 $211.13

78597 26 $36.61

78597 TC $174.53

78598 $320.58

78598 26 $42.52

78598 TC $278.06

78600 $193.01

78600 26 $22.56

78600 TC $170.46

78601 $227.77

78601 26 $25.88

78601 TC $201.89

78605 $209.65

78605 26 $27.36

78605 TC $182.29

78606 $348.31

78606 26 $32.54

78606 TC $315.77

207 of 300


ND Medicaid


as of 7/1/2020



78608 $1,515.01

78608 26 $73.95

78608 TC $1,442.68

78609 $78.39

78609 26 $78.39

78610 $183.40

78610 26 $15.53

78610 TC $167.87

78630 $356.08

78630 26 $34.76

78630 TC $321.32

78635 $356.08

78635 26 $31.80

78635 TC $324.28

78645 $341.66

78645 26 $28.47

78645 TC $313.19

78650 $291.00

78650 26 $26.99

78650 TC $264.01

78660 $193.75

78660 26 $27.36

78660 TC $166.39

78700 $179.70

78700 26 $22.56

78700 TC $157.15

78701 $229.62

78701 26 $24.77

78701 TC $204.85

78707 $244.78

78707 26 $48.44

78707 TC $196.34

78708 $185.62

78708 26 $61.01

78708 TC $124.61

208 of 300


ND Medicaid


as of 7/1/2020



78709 $386.77

78709 26 $70.62

78709 TC $316.14

78725 $114.26

78725 26 $18.86

78725 TC $95.40

78730 $79.87

78730 26 $8.13

78730 TC $71.73

78740 $228.14

78740 26 $28.10

78740 TC $200.04

78761 $222.96

78761 26 $36.98

78761 TC $185.99

78800 $272.51

78800 26 $32.91

78800 TC $239.60

78801 $299.13

78801 26 $37.35

78801 TC $261.79

78802 $329.08

78802 26 $39.93

78802 TC $289.15

78803 $409.69

78803 26 $54.35

78803 TC $355.34

78804 $695.51

78804 26 $51.03

78804 TC $644.49

78808 $41.78

78811 $1,347.72

78811 26 $77.65

78811 TC $1,271.97

78812 $1,536.11

209 of 300


ND Medicaid


as of 7/1/2020



78812 26 $95.77

78812 TC $1,442.68

78813 $1,536.84

78813 26 $96.51

78813 TC $1,442.68

78814 $1,549.63

78814 26 $109.45

78814 TC $1,442.68

78815 $1,562.63

78815 26 $122.76

78815 TC $1,442.68

78816 $1,563.71

78816 26 $123.87

78816 TC $1,442.68

78830 $518.03

78830 26 $74.32

78830 TC $443.71

78831 $749.13

78831 26 $90.59

78831 TC $658.54

78832 $976.16

78832 26 $105.75

78832 TC $870.41

78835 $108.34

78835 26 $23.29

78835 TC $85.04

79005 $143.10

79005 26 $90.96

79005 TC $52.14

79101 $154.56

79101 26 $101.68

79101 TC $52.88

79200 $141.99

79200 26 $86.89

79200 TC $55.09

210 of 300


ND Medicaid


as of 7/1/2020



79300 26 $69.51

79403 $197.08

79403 26 $112.78

79403 TC $84.30

79440 $127.94

79440 26 $86.89

79440 TC $41.04

79445 26 $117.58

80047 $13.73

80048 $8.46

80051 $7.01

80053 $10.56

80055 $47.81

80061 $13.39

80069 $8.68

80074 $47.63

80076 $8.17

80081 $74.86

80145 $38.57

80150 $15.08

80155 $38.57

80156 $14.57

80157 $13.25

80158 $18.05

80159 $20.15

80162 $13.28

80163 $13.28

80164 $13.54

80165 $13.54

80168 $16.34

80169 $13.73

80170 $16.38

80171 $21.67

80173 $15.78

80175 $13.25

211 of 300


ND Medicaid


as of 7/1/2020



80176 $14.69

80177 $13.25

80178 $6.61

80180 $18.05

80183 $13.25

80184 $15.30

80185 $13.25

80186 $13.76

80187 $27.11

80188 $16.59

80190 $60.00

80192 $16.75

80194 $14.60

80195 $13.73

80197 $13.73

80198 $14.14

80199 $27.11

80200 $16.13

80201 $11.92

80202 $13.54

80203 $13.25

80230 $38.57

80235 $27.11

80280 $38.57

80285 $27.11

80299 $18.64

80305 $12.60

80306 $17.14

80307 $62.14

80400 $32.62

80402 $86.96

80406 $78.26

80408 $125.50

80410 $80.37

80412 $801.62

212 of 300


ND Medicaid


as of 7/1/2020



80414 $51.64

80415 $55.89

80416 $209.32

80417 $43.99

80418 $579.48

80420 $161.88

80422 $46.07

80424 $50.50

80426 $148.41

80428 $66.70

80430 $129.33

80432 $165.61

80434 $285.03

80435 $103.00

80436 $91.16

80438 $50.41

80439 $67.21

80500 $23.29

80502 $76.54

81000 $4.02

81001 $3.17

81002 $3.48

81003 $2.25

81005 $2.17

81007 $29.98

81015 $3.05

81020 $4.70

81025 $8.61

81050 $3.64

81105 $122.22

81106 $122.22

81107 $122.22

81108 $122.22

81109 $122.22

81110 $122.22

213 of 300


ND Medicaid


as of 7/1/2020



81111 $122.22

81112 $122.22

81120 $193.25

81121 $295.79

81161 $279.00

81162 $1,824.88

81163 $936.00

81164 $584.23

81165 $565.76

81166 $301.35

81167 $282.88

81170 $300.00

81171 $137.00

81172 $274.83

81173 $301.35

81174 $185.20

81175 $676.50

81176 $241.90

81177 $137.00

81178 $137.00

81179 $137.00

81180 $137.00

81181 $137.00

81182 $137.00

81183 $137.00

81184 $137.00

81185 $846.27

81186 $185.20

81187 $137.00

81188 $137.00

81189 $274.83

81190 $185.20

81200 $47.25

81201 $780.00

81202 $280.00

214 of 300


ND Medicaid


as of 7/1/2020



81203 $200.00

81204 $137.00

81205 $94.99

81206 $163.96

81207 $144.84

81208 $214.62

81209 $39.31

81210 $175.40

81212 $440.00

81215 $375.25

81216 $185.12

81217 $375.25

81218 $241.90

81219 $121.63

81220 $556.60

81221 $97.22

81222 $435.07

81223 $499.00

81224 $168.75

81225 $291.36

81226 $450.91

81227 $174.81

81228 $900.00

81229 $1,160.00

81230 $174.81

81231 $174.81

81232 $174.81

81233 $175.40

81234 $137.00

81235 $324.58

81236 $282.88

81237 $175.40

81238 $600.00

81239 $274.83

81240 $65.69

215 of 300


ND Medicaid


as of 7/1/2020



81241 $73.37

81242 $36.62

81243 $57.04

81244 $44.89

81245 $165.51

81246 $83.00

81247 $174.81

81248 $375.25

81249 $600.00

81250 $58.49

81251 $47.25

81252 $101.12

81253 $61.52

81254 $35.00

81255 $51.45

81256 $65.36

81257 $102.26

81258 $375.25

81259 $600.00

81260 $39.31

81261 $197.99

81262 $68.55

81263 $294.52

81264 $172.73

81265 $233.07

81266 $304.81

81267 $207.46

81268 $260.79

81269 $202.40

81270 $91.66

81271 $137.00

81272 $329.51

81273 $124.87

81274 $274.83

81275 $193.25

216 of 300


ND Medicaid


as of 7/1/2020



81276 $193.25

81277 $1,160.00

81283 $73.37

81284 $137.00

81285 $274.83

81286 $274.83

81287 $124.64

81288 $192.32

81289 $185.20

81290 $39.31

81291 $65.34

81292 $675.40

81293 $331.00

81294 $202.40

81295 $381.70

81296 $337.73

81297 $213.30

81298 $641.85

81299 $308.00

81300 $238.00

81301 $348.56

81302 $527.87

81303 $120.00

81304 $150.00

81305 $175.40

81306 $291.36

81307 $282.88

81308 $301.35

81309 $274.83

81310 $246.52

81311 $295.79

81312 $137.00

81313 $255.05

81314 $329.51

81315 $207.31

217 of 300


ND Medicaid


as of 7/1/2020



81316 $207.31

81317 $676.50

81318 $331.00

81319 $203.50

81320 $291.36

81321 $600.00

81322 $46.60

81323 $300.00

81324 $758.36

81325 $769.58

81326 $46.60

81327 $192.00

81328 $174.81

81329 $137.00

81330 $47.00

81331 $51.07

81332 $43.65

81333 $137.00

81334 $329.51

81335 $174.81

81336 $301.35

81337 $185.20

81340 $208.92

81341 $49.59

81342 $201.50

81343 $137.00

81344 $137.00

81345 $185.20

81346 $174.81

81350 $234.00

81355 $88.20

81361 $174.81

81362 $375.25

81363 $202.40

81364 $324.58

218 of 300


ND Medicaid


as of 7/1/2020



81370 $402.12

81371 $404.52

81372 $403.59

81373 $127.43

81374 $74.33

81375 $220.74

81376 $122.22

81377 $94.74

81378 $345.57

81379 $335.38

81380 $177.25

81381 $169.90

81382 $123.68

81383 $109.13

81400 $63.96

81401 $137.00

81402 $150.33

81403 $185.20

81404 $274.83

81405 $301.35

81406 $282.88

81407 $846.27

81408 $2,000.00

81410 $504.00

81411 $1,350.19

81412 $2,448.56

81413 $584.90

81414 $584.90

81415 $4,780.00

81416 $12,000.00

81417 $320.00

81420 $759.05

81422 $759.05

81425 $5,031.20

81426 $2,709.95

219 of 300


ND Medicaid


as of 7/1/2020



81427 $2,337.65

81430 $1,625.00

81431 $679.57

81432 $679.05

81433 $438.93

81434 $597.91

81435 $584.90

81436 $584.90

81437 $438.93

81438 $438.93

81439 $584.90

81440 $3,324.00

81442 $2,143.60

81443 $2,448.56

81445 $597.91

81448 $584.90

81450 $759.53

81455 $2,919.60

81460 $1,287.00

81465 $936.00

81470 $914.00

81471 $914.00

81490 $840.65

81493 $1,050.00

81500 $260.50

81503 $897.00

81504 $520.00

81506 $68.92

81507 $795.00

81508 $54.30

81509 $1,487.37

81510 $55.54

81511 $153.50

81512 $69.52

81518 $3,873.00

220 of 300


ND Medicaid


as of 7/1/2020



81519 $3,873.00

81520 $2,510.21

81521 $3,873.00

81522 $3,873.00

81525 $3,116.00

81528 $508.87

81535 $579.46

81536 $177.56

81538 $2,871.00

81539 $760.00

81540 $3,750.00

81541 $3,873.00

81545 $3,600.00

81551 $2,030.00

81595 $3,240.00

81596 $72.19

82009 $4.52

82010 $8.17

82013 $12.29

82016 $16.49

82017 $16.87

82024 $38.62

82030 $25.80

82040 $4.95

82042 $7.78

82043 $5.78

82044 $6.23

82045 $33.94

82075 $30.00

82085 $9.71

82088 $40.75

82103 $13.44

82104 $14.46

82105 $16.77

82106 $17.00

221 of 300


ND Medicaid


as of 7/1/2020



82107 $64.41

82108 $25.48

82120 $5.99

82127 $14.18

82128 $13.87

82131 $22.98

82135 $16.45

82136 $19.61

82139 $16.87

82140 $14.57

82143 $9.35

82150 $6.48

82154 $28.83

82157 $29.28

82160 $25.55

82163 $20.52

82164 $14.60

82172 $21.09

82175 $18.97

82180 $9.89

82190 $15.90

82232 $16.18

82239 $17.12

82240 $26.58

82247 $5.02

82248 $5.02

82252 $4.56

82261 $16.87

82270 $4.38

82271 $5.32

82272 $4.23

82274 $15.92

82286 $5.16

82300 $23.64

82306 $29.60

222 of 300


ND Medicaid


as of 7/1/2020



82308 $26.79

82310 $5.16

82330 $13.68

82331 $13.34

82340 $6.03

82355 $11.58

82360 $12.87

82365 $12.90

82370 $12.52

82373 $18.06

82374 $4.88

82375 $12.32

82376 $14.07

82378 $18.96

82379 $16.87

82380 $9.22

82382 $27.30

82383 $29.08

82384 $25.25

82387 $18.06

82390 $10.74

82397 $14.12

82415 $12.67

82435 $4.60

82436 $5.75

82438 $5.00

82441 $6.01

82465 $4.35

82480 $7.87

82482 $9.81

82485 $20.65

82495 $20.28

82507 $27.80

82523 $18.68

82525 $12.41

223 of 300


ND Medicaid


as of 7/1/2020



82528 $22.52

82530 $16.71

82533 $16.30

82540 $4.64

82542 $24.09

82550 $6.51

82552 $13.39

82553 $11.55

82554 $11.87

82565 $5.12

82570 $5.18

82575 $9.46

82585 $14.14

82595 $6.47

82600 $19.40

82607 $15.08

82608 $14.32

82610 $18.52

82615 $9.55

82626 $25.27

82627 $22.23

82633 $30.98

82634 $29.28

82638 $12.25

82642 $29.28

82652 $38.50

82656 $11.53

82657 $22.17

82658 $44.03

82664 $61.50

82668 $18.79

82670 $27.94

82671 $32.30

82672 $21.70

82677 $24.18

224 of 300


ND Medicaid


as of 7/1/2020



82679 $24.95

82693 $14.90

82696 $26.24

82705 $5.10

82710 $16.80

82715 $22.97

82725 $18.77

82726 $19.75

82728 $13.63

82731 $64.41

82735 $18.54

82746 $14.70

82747 $17.65

82757 $17.34

82759 $21.48

82760 $11.20

82775 $21.07

82776 $11.74

82777 $44.25

82784 $9.30

82785 $16.46

82787 $8.02

82800 $11.00

82803 $26.07

82805 $78.77

82810 $9.77

82820 $13.34

82930 $6.71

82938 $17.69

82941 $17.63

82943 $14.29

82945 $3.93

82946 $17.77

82947 $3.93

82948 $5.04

225 of 300


ND Medicaid


as of 7/1/2020



82950 $4.75

82951 $12.87

82952 $3.92

82955 $9.70

82960 $6.05

82962 $3.28

82963 $21.48

82965 $13.15

82977 $7.20

82978 $15.45

82979 $9.44

82985 $16.76

83001 $18.58

83002 $18.52

83003 $16.67

83006 $75.60

83009 $67.36

83010 $12.58

83012 $26.89

83013 $67.36

83014 $7.86

83015 $20.94

83018 $21.96

83020 $12.87

83020 26 $19.23

83021 $18.06

83026 $4.01

83030 $10.74

83033 $8.00

83036 $9.71

83037 $9.71

83045 $6.49

83050 $8.20

83051 $7.31

83060 $8.80

226 of 300


ND Medicaid


as of 7/1/2020



83065 $9.00

83068 $9.47

83069 $3.95

83070 $4.75

83080 $16.87

83088 $29.53

83090 $17.92

83150 $22.41

83491 $17.90

83497 $12.90

83498 $27.17

83500 $22.65

83505 $24.30

83516 $11.53

83518 $9.64

83519 $18.40

83520 $17.27

83525 $11.43

83527 $12.95

83528 $19.82

83540 $6.47

83550 $8.74

83570 $8.85

83582 $15.47

83586 $12.80

83593 $28.50

83605 $11.57

83615 $6.04

83625 $12.79

83630 $19.70

83631 $19.63

83632 $20.22

83633 $11.25

83655 $12.11

83661 $21.99

227 of 300


ND Medicaid


as of 7/1/2020



83662 $18.91

83663 $18.91

83664 $19.32

83670 $9.81

83690 $6.89

83695 $14.32

83698 $46.31

83700 $11.26

83701 $33.86

83704 $34.19

83718 $8.19

83719 $12.75

83721 $10.50

83722 $34.19

83727 $17.19

83735 $6.70

83775 $7.37

83785 $26.65

83789 $24.11

83825 $16.26

83835 $16.94

83857 $10.74

83861 $22.48

83864 $28.50

83872 $5.86

83873 $17.20

83874 $12.92

83876 $50.86

83880 $39.26

83883 $13.60

83885 $24.51

83915 $11.15

83916 $27.39

83918 $23.60

83919 $16.45

228 of 300


ND Medicaid


as of 7/1/2020



83921 $21.21

83930 $6.61

83935 $6.82

83937 $29.85

83945 $14.45

83950 $64.41

83951 $64.41

83970 $41.28

83986 $3.58

83987 $3.58

83992 $16.80

83993 $19.63

84030 $5.50

84035 $3.98

84060 $7.64

84066 $9.66

84075 $5.18

84078 $8.26

84080 $14.78

84081 $16.52

84085 $9.44

84087 $10.73

84100 $4.74

84105 $5.78

84106 $5.82

84110 $8.44

84112 $98.11

84119 $13.36

84120 $14.71

84126 $39.11

84132 $4.76

84133 $4.73

84134 $14.59

84135 $21.27

84138 $21.05

229 of 300


ND Medicaid


as of 7/1/2020



84140 $20.67

84143 $22.81

84144 $20.86

84145 $27.22

84146 $19.38

84150 $41.77

84152 $18.39

84153 $18.39

84154 $18.39

84155 $3.67

84156 $3.67

84157 $4.00

84160 $5.61

84163 $15.05

84165 $10.74

84165 26 $19.23

84166 $17.83

84166 26 $19.23

84181 $17.03

84181 26 $19.23

84182 $29.21

84182 26 $19.23

84202 $14.35

84203 $9.74

84206 $26.69

84207 $28.10

84210 $14.48

84220 $9.44

84228 $11.63

84233 $87.88

84234 $64.88

84235 $71.23

84238 $36.57

84244 $21.99

84252 $20.24

230 of 300


ND Medicaid


as of 7/1/2020



84255 $25.53

84260 $30.98

84270 $21.73

84275 $13.44

84285 $25.21

84295 $4.81

84300 $5.06

84302 $4.86

84305 $21.26

84307 $18.28

84311 $8.10

84315 $3.28

84375 $39.00

84376 $5.50

84377 $5.50

84378 $11.53

84379 $11.53

84392 $5.49

84402 $25.47

84403 $25.81

84410 $51.28

84425 $21.23

84430 $11.63

84431 $35.11

84432 $16.06

84436 $6.87

84437 $6.47

84439 $9.02

84442 $14.78

84443 $16.80

84445 $50.86

84446 $14.18

84449 $18.00

84450 $5.18

84460 $5.30

231 of 300


ND Medicaid


as of 7/1/2020



84466 $12.76

84478 $5.74

84479 $6.47

84480 $14.18

84481 $16.94

84482 $15.76

84484 $12.47

84485 $7.20

84488 $7.30

84490 $9.93

84510 $10.63

84512 $10.09

84520 $3.95

84525 $5.13

84540 $5.56

84545 $7.20

84550 $4.52

84560 $5.08

84577 $16.80

84578 $4.47

84580 $9.55

84583 $6.05

84585 $15.50

84586 $35.33

84588 $33.94

84590 $11.61

84591 $17.06

84597 $13.72

84600 $17.11

84620 $12.91

84630 $11.39

84681 $20.81

84702 $15.05

84703 $7.52

84704 $15.29

232 of 300


ND Medicaid


as of 7/1/2020



84830 $12.70

85002 $4.82

85004 $6.47

85007 $3.80

85008 $3.43

85009 $5.07

85013 $7.00

85014 $2.37

85018 $2.37

85025 $7.77

85027 $6.47

85032 $4.31

85041 $3.02

85044 $4.31

85045 $3.99

85046 $5.57

85048 $2.54

85049 $4.48

85055 $35.74

85060 $25.14

85097 $72.10

85130 $11.89

85170 $16.30

85175 $20.37

85210 $12.98

85220 $17.65

85230 $17.90

85240 $17.90

85244 $20.42

85245 $22.94

85246 $22.94

85247 $22.94

85250 $19.04

85260 $17.90

85270 $17.90

233 of 300


ND Medicaid


as of 7/1/2020



85280 $19.35

85290 $16.34

85291 $9.11

85292 $18.93

85293 $18.93

85300 $11.85

85301 $10.81

85302 $12.01

85303 $13.84

85305 $11.61

85306 $15.32

85307 $15.32

85335 $12.87

85337 $17.27

85345 $4.69

85347 $4.28

85348 $4.49

85360 $8.41

85362 $6.89

85366 $80.46

85370 $12.43

85378 $9.72

85379 $10.18

85380 $10.18

85384 $9.72

85385 $14.46

85390 $15.48

85390 26 $38.82

85396 $21.08

85397 $30.86

85400 $7.71

85410 $7.71

85415 $17.19

85420 $6.53

85421 $10.18

234 of 300


ND Medicaid


as of 7/1/2020



85441 $4.20

85445 $6.82

85460 $7.73

85461 $9.36

85475 $8.87

85520 $13.09

85525 $11.84

85530 $13.09

85536 $6.88

85540 $8.60

85547 $8.60

85549 $18.75

85555 $7.47

85557 $13.36

85576 $24.91

85576 26 $19.23

85597 $17.98

85598 $17.98

85610 $4.29

85611 $3.94

85612 $17.49

85613 $9.58

85635 $9.85

85651 $4.27

85652 $2.70

85660 $5.51

85670 $5.77

85675 $6.85

85705 $9.63

85730 $6.01

85732 $6.47

85810 $11.67

86000 $6.98

86001 $7.82

86003 $5.22

235 of 300


ND Medicaid


as of 7/1/2020



86005 $7.97

86008 $17.93

86021 $15.05

86022 $18.37

86023 $12.46

86038 $12.09

86039 $11.16

86060 $7.30

86063 $5.77

86077 $56.57

86078 $56.57

86079 $56.57

86140 $5.18

86141 $12.95

86146 $25.45

86147 $25.45

86148 $16.07

86152 $250.78

86153 26 $35.87

86155 $15.99

86156 $8.07

86157 $8.06

86160 $12.00

86161 $12.00

86162 $20.32

86171 $10.01

86200 $12.95

86215 $13.25

86225 $13.74

86226 $12.11

86235 $17.93

86255 $12.05

86255 26 $19.23

86256 $12.05

86256 26 $19.23

236 of 300


ND Medicaid


as of 7/1/2020



86277 $15.74

86280 $8.19

86294 $25.57

86300 $20.81

86301 $20.81

86304 $20.81

86305 $20.81

86308 $5.18

86309 $6.47

86310 $7.37

86316 $20.81

86317 $14.99

86318 $18.09

86320 $29.92

86320 26 $19.23

86325 $23.13

86325 26 $19.23

86327 $29.92

86327 26 $23.29

86329 $14.05

86331 $11.98

86332 $24.37

86334 $22.34

86334 26 $19.23

86335 $29.35

86335 26 $19.23

86336 $15.59

86337 $21.41

86340 $15.08

86341 $23.57

86343 $12.46

86344 $10.39

86352 $135.86

86353 $49.03

86355 $37.73

237 of 300


ND Medicaid


as of 7/1/2020



86356 $26.78

86357 $37.73

86359 $37.73

86360 $46.98

86361 $26.78

86367 $77.78

86376 $14.55

86382 $16.91

86384 $13.61

86386 $21.78

86403 $11.54

86406 $10.64

86430 $6.14

86431 $5.67

86480 $61.98

86481 $100.00

86486 $5.18

86490 $91.33

86510 $6.66

86580 $9.24

86590 $12.66

86592 $4.27

86593 $4.40

86602 $10.18

86603 $12.87

86606 $15.05

86609 $12.88

86611 $10.18

86612 $12.90

86615 $13.19

86617 $15.49

86618 $17.03

86619 $13.38

86622 $8.93

86625 $13.12

238 of 300


ND Medicaid


as of 7/1/2020



86628 $12.01

86631 $11.82

86632 $12.68

86635 $11.47

86638 $12.12

86641 $14.41

86644 $14.39

86645 $16.85

86648 $15.21

86651 $13.19

86652 $13.19

86653 $13.19

86654 $13.19

86658 $13.03

86663 $13.12

86664 $15.29

86665 $18.14

86666 $10.18

86668 $14.16

86671 $12.25

86674 $14.72

86677 $16.85

86682 $13.01

86684 $15.84

86687 $9.09

86688 $14.00

86689 $19.35

86692 $17.16

86694 $14.39

86695 $13.19

86696 $19.35

86698 $13.79

86701 $8.89

86702 $13.52

86703 $13.71

239 of 300


ND Medicaid


as of 7/1/2020



86704 $12.05

86705 $11.77

86706 $10.74

86707 $11.57

86708 $12.39

86709 $11.26

86710 $13.55

86711 $16.89

86713 $15.30

86717 $12.25

86720 $16.20

86723 $13.19

86727 $12.87

86732 $15.00

86735 $13.05

86738 $13.24

86741 $13.19

86744 $15.99

86747 $15.03

86750 $13.19

86753 $12.39

86756 $15.89

86757 $19.35

86759 $18.23

86762 $14.39

86765 $12.88

86768 $13.19

86771 $24.48

86774 $14.80

86777 $14.39

86778 $14.41

86780 $13.24

86784 $12.56

86787 $12.88

86788 $16.85

240 of 300


ND Medicaid


as of 7/1/2020



86789 $14.39

86790 $12.88

86793 $13.19

86794 $16.85

86800 $15.91

86803 $14.27

86804 $15.49

86805 $189.51

86806 $47.59

86807 $78.65

86808 $29.68

86812 $25.81

86813 $58.00

86816 $30.17

86817 $106.14

86821 $36.56

86825 $109.49

86826 $36.53

86828 $64.19

86829 $64.19

86830 $95.52

86831 $81.88

86832 $323.75

86833 $325.80

86834 $357.56

86835 $322.96

86850 $9.77

86880 $5.39

86885 $5.72

86886 $5.18

86900 $2.99

86901 $2.99

86902 $6.35

86904 $16.34

86905 $3.83

241 of 300


ND Medicaid


as of 7/1/2020



86906 $7.75

86940 $8.77

86941 $12.11

87003 $16.84

87015 $6.68

87040 $10.32

87045 $9.44

87046 $9.44

87070 $8.62

87071 $9.89

87073 $9.66

87075 $9.47

87076 $8.08

87077 $8.08

87081 $6.63

87084 $27.07

87086 $8.07

87088 $8.09

87101 $7.71

87102 $8.41

87103 $20.46

87106 $10.32

87107 $10.32

87109 $15.39

87110 $19.60

87116 $10.80

87118 $14.61

87140 $5.57

87143 $12.52

87147 $5.18

87149 $20.05

87150 $35.09

87152 $7.74

87153 $115.36

87158 $7.74

242 of 300


ND Medicaid


as of 7/1/2020



87164 $10.74

87164 26 $20.71

87166 $11.30

87168 $4.27

87169 $4.31

87172 $4.27

87176 $5.88

87177 $8.90

87181 $4.75

87184 $7.48

87185 $4.75

87186 $8.65

87187 $40.17

87188 $6.64

87190 $7.31

87197 $15.02

87205 $4.27

87206 $5.39

87207 $5.99

87207 26 $19.23

87209 $17.98

87210 $5.82

87220 $4.27

87230 $19.74

87250 $19.56

87252 $26.07

87253 $20.20

87254 $19.56

87255 $33.86

87260 $14.43

87265 $11.98

87267 $13.42

87269 $13.61

87270 $11.98

87271 $13.42

243 of 300


ND Medicaid


as of 7/1/2020



87272 $11.98

87273 $11.98

87274 $11.98

87275 $12.25

87276 $16.07

87278 $15.60

87279 $16.43

87280 $13.42

87281 $11.98

87283 $60.80

87285 $12.18

87290 $13.42

87299 $16.10

87300 $11.98

87301 $11.98

87305 $11.98

87320 $15.00

87324 $11.98

87327 $13.42

87328 $13.82

87329 $11.98

87332 $11.98

87335 $12.66

87336 $16.00

87337 $11.98

87338 $14.38

87339 $16.00

87340 $10.33

87341 $10.33

87350 $11.53

87380 $18.36

87385 $13.25

87389 $24.08

87390 $24.06

87391 $21.90

244 of 300


ND Medicaid


as of 7/1/2020



87400 $14.13

87420 $13.91

87425 $11.98

87427 $11.98

87430 $16.81

87449 $11.98

87450 $9.59

87451 $10.51

87471 $35.09

87472 $42.84

87475 $20.05

87476 $35.09

87480 $20.05

87481 $35.09

87482 $55.74

87483 $416.78

87485 $20.05

87486 $35.09

87487 $42.84

87490 $22.75

87491 $35.09

87492 $53.47

87493 $37.27

87495 $30.03

87496 $35.09

87497 $42.84

87498 $35.09

87500 $35.09

87501 $51.31

87502 $95.80

87503 $29.22

87505 $128.29

87506 $262.99

87507 $416.78

87510 $20.05

245 of 300


ND Medicaid


as of 7/1/2020



87511 $35.09

87512 $41.76

87516 $35.09

87517 $42.84

87520 $31.22

87521 $35.09

87522 $42.84

87525 $29.80

87526 $39.26

87527 $41.76

87528 $20.05

87529 $35.09

87530 $42.84

87531 $58.00

87532 $35.09

87533 $41.76

87534 $21.92

87535 $35.09

87536 $85.10

87537 $21.92

87538 $35.09

87539 $58.62

87540 $20.05

87541 $35.09

87542 $41.76

87550 $20.05

87551 $48.24

87552 $42.84

87555 $26.88

87556 $41.68

87557 $42.84

87560 $27.29

87561 $35.09

87562 $42.84

87563 $35.09

246 of 300


ND Medicaid


as of 7/1/2020



87580 $20.05

87581 $35.09

87582 $302.62

87590 $26.88

87591 $35.09

87592 $42.84

87623 $35.09

87624 $35.09

87625 $40.55

87631 $142.63

87632 $218.06

87633 $416.78

87634 $70.20

87635 $51.31

87640 $35.09

87641 $35.09

87650 $20.05

87651 $35.09

87652 $41.76

87653 $35.09

87660 $20.05

87661 $35.09

87662 $51.31

87797 $30.03

87798 $35.09

87799 $42.84

87800 $43.67

87801 $70.20

87802 $12.73

87803 $16.00

87804 $16.55

87806 $32.77

87807 $13.10

87808 $15.29

87809 $21.76

247 of 300


ND Medicaid


as of 7/1/2020



87810 $35.29

87850 $24.56

87880 $16.53

87899 $16.07

87900 $130.35

87901 $257.45

87902 $257.45

87903 $488.66

87904 $26.07

87905 $12.22

87906 $128.73

87910 $257.45

87912 $257.45

88104 $71.36

88104 26 $29.95

88104 TC $41.41

88106 $67.67

88106 26 $20.71

88106 TC $46.96

88108 $64.71

88108 26 $24.03

88108 TC $40.67

88112 $70.25

88112 26 $29.58

88112 TC $40.67

88120 $603.08

88120 26 $61.38

88120 TC $541.70

88121 $460.72

88121 26 $51.77

88121 TC $408.95

88125 $27.73

88125 26 $14.79

88125 TC $12.94

88130 $17.98

248 of 300


ND Medicaid


as of 7/1/2020



88140 $7.99

88141 $26.62

88142 $20.26

88143 $23.04

88147 $50.56

88148 $16.00

88150 $15.12

88152 $27.64

88153 $24.03

88155 $14.65

88160 $74.32

88160 26 $27.73

88160 TC $46.59

88161 $71.36

88161 26 $26.99

88161 TC $44.37

88162 $102.79

88162 26 $40.67

88162 TC $62.12

88164 $15.12

88165 $42.22

88166 $15.12

88167 $15.12

88172 $58.42

88172 26 $38.45

88172 TC $19.97

88173 $160.11

88173 26 $75.06

88173 TC $85.04

88174 $25.37

88175 $26.61

88177 $30.69

88177 26 $23.29

88177 TC $7.40

88182 $143.47

249 of 300


ND Medicaid


as of 7/1/2020



88182 26 $41.41

88182 TC $102.05

88184 $69.51

88185 $22.92

88187 $39.19

88188 $66.56

88189 $89.11

88230 $116.49

88233 $140.73

88235 $150.30

88237 $143.75

88239 $147.52

88240 $13.07

88241 $12.09

88245 $173.17

88248 $173.17

88249 $173.17

88261 $264.34

88262 $125.49

88263 $150.29

88264 $144.61

88267 $188.57

88269 $173.66

88271 $21.42

88272 $40.70

88273 $34.81

88274 $42.38

88275 $51.19

88280 $33.47

88283 $68.60

88285 $26.91

88289 $34.43

88291 $34.76

88300 $16.27

88300 26 $4.81

250 of 300


ND Medicaid


as of 7/1/2020



88300 TC $11.46

88302 $32.17

88302 26 $7.40

88302 TC $24.77

88304 $42.89

88304 26 $12.20

88304 TC $30.69

88305 $73.21

88305 26 $40.30

88305 TC $32.91

88307 $287.67

88307 26 $88.37

88307 TC $199.30

88309 $437.05

88309 26 $155.67

88309 TC $281.39

88311 $22.56

88311 26 $13.31

88311 TC $9.24

88312 $109.82

88312 26 $28.47

88312 TC $81.35

88313 $79.13

88313 26 $12.94

88313 TC $66.19

88314 $100.94

88314 26 $23.66

88314 TC $77.28

88319 $116.47

88319 26 $28.84

88319 TC $87.63

88321 $103.16

88323 $119.80

88323 26 $92.81

88323 TC $26.99

251 of 300


ND Medicaid


as of 7/1/2020



88325 $181.18

88329 $54.72

88331 $102.05

88331 26 $66.56

88331 TC $35.50

88332 $56.94

88332 26 $33.28

88332 TC $23.66

88333 $93.55

88333 26 $66.56

88333 TC $26.99

88334 $58.79

88334 26 $40.30

88334 TC $18.49

88341 $96.14

88341 26 $29.95

88341 TC $66.19

88342 $109.82

88342 26 $37.72

88342 TC $72.10

88344 $179.70

88344 26 $41.04

88344 TC $138.66

88346 $131.63

88346 26 $38.45

88346 TC $93.18

88348 $402.30

88348 26 $81.35

88348 TC $320.95

88350 $96.51

88350 26 $31.06

88350 TC $65.45

88355 $143.47

88355 26 $88.00

88355 TC $55.46

252 of 300


ND Medicaid


as of 7/1/2020



88356 $244.78

88356 26 $136.44

88356 TC $108.34

88358 $138.66

88358 26 $53.25

88358 TC $85.41

88360 $130.52

88360 26 $45.11

88360 TC $85.41

88361 $132.37

88361 26 $47.70

88361 TC $84.67

88362 $236.65

88362 26 $119.80

88362 TC $116.84

88363 $24.40

88364 $143.84

88364 26 $36.98

88364 TC $106.86

88365 $187.84

88365 26 $46.59

88365 TC $141.25

88366 $287.67

88366 26 $66.19

88366 TC $221.49

88367 $117.95

88367 26 $36.61

88367 TC $81.35

88368 $136.44

88368 26 $44.00

88368 TC $92.44

88369 $119.43

88369 26 $34.76

88369 TC $84.67

88371 $22.23

253 of 300


ND Medicaid


as of 7/1/2020



88371 26 $20.71

88372 $26.22

88372 26 $19.23

88373 $76.54

88373 26 $28.10

88373 TC $48.44

88374 $356.82

88374 26 $47.33

88374 TC $309.49

88375 $51.40

88377 $421.15

88377 26 $68.77

88377 TC $352.38

88380 $140.51

88380 26 $58.79

88380 TC $81.72

88381 $187.10

88381 26 $26.62

88381 TC $160.47

88387 $36.98

88387 26 $29.58

88387 TC $7.40

88388 $38.45

88388 26 $25.51

88388 TC $12.94

88720 $5.02

88738 $5.02

88740 $9.37

88741 $9.37

89049 $261.42

89050 $4.72

89051 $5.60

89055 $4.27

89060 $7.33

89060 26 $19.23

254 of 300


ND Medicaid


as of 7/1/2020



89125 $5.88

89160 $4.85

89190 $5.79

89220 $16.64

89230 $2.22

90371 $115.94

90375 $277.34

90376 $278.70

90471 $16.20

90472 $16.20

90473 $16.20

90474 $16.20

90785 $15.53

90791 $146.79

90792 $162.69

90832 $71.73

90833 $73.58

90834 $95.40

90836 $93.18

90837 $142.73

90838 $122.39

90839 $149.01

90840 $71.36

90845 $100.94

90846 $104.27

90847 $107.97

90849 $37.35

90853 $28.47

90865 $175.27

90870 $182.66

90875 $63.23

90876 $110.93

90880 $112.04

90901 $42.15

90912 $82.83

255 of 300


ND Medicaid


as of 7/1/2020



90913 $33.28

90935 $75.06

90937 $107.60

90945 $88.37

90947 $127.94

90951 $961.00

90954 $834.17

90955 $470.70

90956 $327.61

90957 $661.87

90958 $450.00

90959 $304.31

90960 $292.48

90961 $245.89

90962 $189.69

90963 $559.44

90964 $489.19

90965 $467.74

90966 $245.52

90967 $18.49

90968 $16.27

90969 $15.53

90970 $8.13

90989 $639.02

90997 $92.44

91010 $209.28

91010 26 $68.77

91010 TC $140.51

91013 $26.62

91013 26 $9.61

91013 TC $17.01

91020 $270.29

91020 26 $77.28

91020 TC $193.01

91022 $174.90

256 of 300


ND Medicaid


as of 7/1/2020



91022 26 $77.28

91022 TC $97.62

91030 $144.58

91030 26 $48.81

91030 TC $95.77

91034 $198.56

91034 26 $52.14

91034 TC $146.42

91035 $505.09

91035 26 $85.78

91035 TC $419.31

91037 $173.42

91037 26 $52.14

91037 TC $121.28

91038 $459.61

91038 26 $59.16

91038 TC $400.45

91040 $530.60

91040 26 $52.51

91040 TC $478.10

91065 $83.57

91065 26 $10.72

91065 TC $72.84

91110 $899.62

91110 26 $133.85

91110 TC $765.77

91111 $904.43

91111 26 $53.98

91111 TC $850.44

91112 $1,513.79

91112 26 $112.78

91112 TC $1,401.01

91117 $141.99

91120 $509.16

91120 26 $51.40

257 of 300


ND Medicaid


as of 7/1/2020



91120 TC $457.76

91122 $261.42

91122 26 $92.44

91122 TC $168.98

91132 $337.96

91132 26 $28.10

91132 TC $309.86

91133 $362.36

91133 26 $35.50

91133 TC $326.87

91200 $38.82

91200 26 $14.79

91200 TC $24.03

92002 $87.26

92004 $155.30

92012 $91.33

92014 $130.15

92015 $20.34

92018 $147.90

92019 $75.43

92020 $28.47

92025 $38.45

92025 26 $20.71

92025 TC $17.75

92060 $66.19

92060 26 $39.56

92060 TC $26.62

92065 $55.09

92065 26 $18.86

92065 TC $36.24

92071 $38.82

92072 $133.11

92081 $35.13

92081 26 $17.01

92081 TC $18.12

258 of 300


ND Medicaid


as of 7/1/2020



92082 $49.55

92082 26 $22.56

92082 TC $26.99

92083 $65.82

92083 26 $28.84

92083 TC $36.98

92100 $85.78

92132 $32.91

92132 26 $17.38

92132 TC $15.53

92133 $38.82

92133 26 $23.29

92133 TC $15.53

92134 $42.52

92134 26 $26.62

92134 TC $15.90

92136 $65.08

92136 26 $32.54

92136 TC $32.54

92145 $15.53

92145 26 $8.13

92145 TC $7.40

92201 $25.88

92202 $16.27

92227 $13.68

92228 $35.50

92228 26 $21.82

92228 TC $13.68

92230 $79.87

92235 $108.34

92235 26 $45.11

92235 TC $63.23

92240 $209.65

92240 26 $48.81

92240 TC $160.84

259 of 300


ND Medicaid


as of 7/1/2020



92242 $248.11

92242 26 $56.94

92242 TC $191.16

92250 $46.96

92250 26 $22.56

92250 TC $24.40

92260 $19.97

92265 $90.59

92265 26 $48.81

92265 TC $41.78

92270 $100.57

92270 26 $44.37

92270 TC $56.20

92273 $135.33

92273 26 $38.45

92273 TC $96.88

92274 $92.07

92274 26 $34.39

92274 TC $57.68

92283 $55.09

92283 26 $9.61

92283 TC $45.48

92284 $61.38

92284 26 $12.94

92284 TC $48.44

92285 $22.92

92285 26 $3.33

92285 TC $19.60

92286 $40.67

92286 26 $23.29

92286 TC $17.38

92287 $164.17

92287 26 $48.44

92287 TC $115.73

92310 $103.90

260 of 300


ND Medicaid


as of 7/1/2020



92311 $108.71

92312 $126.09

92313 $102.05

92314 $88.74

92315 $81.72

92316 $101.68

92317 $85.41

92325 $45.85

92326 $38.82

92340 $35.87

92341 $41.41

92342 $44.37

92370 $31.80

92502 $97.62

92504 $29.95

92507 $82.09

92508 $24.77

92511 $116.47

92512 $61.38

92516 $70.99

92520 $83.20

92521 $117.21

92522 $95.40

92523 $201.15

92524 $93.18

92526 $90.59

92537 $43.63

92537 26 $33.28

92537 TC $10.35

92538 $23.66

92538 26 $17.01

92538 TC $6.66

92540 $111.67

92540 26 $82.83

92540 TC $28.84

261 of 300


ND Medicaid


as of 7/1/2020



92541 $26.62

92541 26 $22.19

92541 TC $4.44

92542 $31.06

92542 26 $26.62

92542 TC $4.44

92544 $18.49

92544 26 $15.16

92544 TC $3.33

92545 $17.38

92545 26 $14.05

92545 TC $3.33

92546 $115.73

92546 26 $15.53

92546 TC $100.20

92547 $8.87

92548 $51.40

92548 26 $36.24

92548 TC $15.16

92549 $65.82

92549 26 $46.96

92549 TC $18.86

92550 $22.92

92551 $11.83

92552 $32.54

92553 $39.56

92555 $24.40

92556 $39.19

92557 $39.19

92558 $9.98

92561 $40.30

92562 $45.85

92563 $31.43

92564 $24.40

92565 $15.90

262 of 300


ND Medicaid


as of 7/1/2020



92567 $16.27

92568 $16.27

92570 $34.02

92571 $27.73

92572 $35.87

92575 $67.67

92576 $37.35

92577 $14.05

92579 $48.07

92582 $76.17

92583 $49.92

92584 $76.54

92585 $140.51

92585 26 $27.73

92585 TC $112.78

92586 $98.73

92587 $23.29

92587 26 $19.60

92587 TC $3.70

92588 $35.50

92588 26 $30.69

92588 TC $4.81

92590 $118.19

92591 $118.19

92592 $25.95

92593 $25.95

92594 $25.95

92595 $25.95

92596 $67.67

92601 $173.05

92602 $108.34

92603 $161.21

92604 $96.51

92607 $133.85

92609 $112.78

263 of 300


ND Medicaid


as of 7/1/2020



92610 $90.22

92611 $95.03

92612 $208.17

92613 $38.82

92614 $154.19

92615 $34.02

92616 $224.81

92617 $42.52

92620 $97.62

92621 $23.29

92625 $72.84

92626 $93.55

92627 $22.19

92640 $118.69

92920 $528.75

92924 $630.07

92928 $587.92

92933 $659.28

92937 $587.18

92941 $660.76

92943 $660.76

92950 $331.30

92953 $0.74

92960 $164.17

92961 $247.37

92970 $187.84

92971 $100.20

92973 $175.64

92974 $160.84

92975 $374.93

92977 $53.61

92978 26 $95.40

92979 26 $76.54

92986 $1,317.08

92987 $1,358.86

264 of 300


ND Medicaid


as of 7/1/2020



92990 $1,084.87

92997 $641.90

92998 $321.32

93000 $17.38

93005 $8.50

93010 $8.50

93015 $73.21

93016 $22.92

93017 $34.76

93018 $15.16

93024 $113.15

93024 26 $59.16

93024 TC $53.98

93025 $146.42

93025 26 $38.45

93025 TC $107.97

93040 $12.94

93041 $5.55

93042 $7.03

93050 $17.01

93050 26 $8.87

93050 TC $8.13

93224 $91.33

93225 $26.25

93226 $37.35

93227 $27.36

93228 $26.99

93229 $731.75

93260 $75.06

93260 26 $45.11

93260 TC $29.95

93261 $68.41

93261 26 $38.82

93261 TC $29.58

93264 $51.77

265 of 300


ND Medicaid


as of 7/1/2020



93268 $207.80

93270 $8.87

93271 $172.31

93272 $26.25

93278 $31.43

93278 26 $13.31

93278 TC $18.12

93279 $62.86

93279 26 $33.65

93279 TC $29.21

93280 $74.69

93280 26 $40.30

93280 TC $34.39

93281 $79.87

93281 26 $44.74

93281 TC $35.13

93282 $76.54

93282 26 $44.74

93282 TC $31.80

93283 $95.40

93283 26 $60.64

93283 TC $34.76

93284 $103.16

93284 26 $65.82

93284 TC $37.35

93285 $55.46

93285 26 $27.36

93285 TC $28.10

93286 $42.15

93286 26 $16.27

93286 TC $25.88

93287 $49.55

93287 26 $24.03

93287 TC $25.51

93288 $51.40

266 of 300


ND Medicaid


as of 7/1/2020



93288 26 $22.19

93288 TC $29.21

93289 $68.77

93289 26 $39.19

93289 TC $29.58

93290 $48.81

93290 26 $22.56

93290 TC $26.25

93291 $45.11

93291 26 $19.60

93291 TC $25.51

93292 $46.22

93292 26 $22.19

93292 TC $24.03

93293 $53.98

93293 26 $15.90

93293 TC $38.09

93294 $31.80

93295 $39.19

93296 $26.25

93297 $27.36

93298 $27.73

93303 $241.82

93303 26 $65.82

93303 TC $176.00

93304 $166.02

93304 26 $37.72

93304 TC $128.31

93306 $215.20

93306 26 $75.80

93306 TC $139.40

93307 $146.42

93307 26 $46.59

93307 TC $99.83

93308 $102.42

267 of 300


ND Medicaid


as of 7/1/2020



93308 26 $26.62

93308 TC $75.80

93312 $255.13

93312 26 $113.52

93312 TC $141.62

93313 $11.83

93314 $243.67

93314 26 $92.81

93314 TC $150.86

93315 26 $133.85

93316 $27.73

93317 26 $94.29

93318 26 $107.60

93320 $55.83

93320 26 $19.23

93320 TC $36.61

93321 $27.36

93321 26 $7.40

93321 TC $19.97

93325 $25.88

93325 26 $3.33

93325 TC $22.56

93350 $196.71

93350 26 $73.58

93350 TC $123.13

93351 $243.30

93351 26 $88.37

93351 TC $154.93

93352 $34.76

93355 $237.38

93356 $41.41

93451 $876.70

93451 26 $132.37

93451 TC $744.32

93452 $942.51

268 of 300


ND Medicaid


as of 7/1/2020



93452 26 $238.49

93452 TC $704.02

93453 $1,212.81

93453 26 $318.36

93453 TC $894.44

93454 $943.62

93454 26 $240.71

93454 TC $702.91

93455 $1,071.93

93455 26 $280.28

93455 TC $791.65

93456 $1,193.95

93456 26 $313.19

93456 TC $880.76

93457 $1,321.88

93457 26 $353.12

93457 TC $968.77

93458 $1,103.73

93458 26 $296.92

93458 TC $806.81

93459 $1,200.60

93459 26 $336.48

93459 TC $864.12

93460 $1,328.54

93460 26 $376.41

93460 TC $952.13

93461 $1,487.54

93461 26 $416.35

93461 TC $1,071.19

93462 $210.02

93463 $101.68

93464 $253.28

93464 26 $92.44

93464 TC $160.84

93503 $90.96

269 of 300


ND Medicaid


as of 7/1/2020



93505 $730.64

93505 26 $224.44

93505 TC $506.20

93530 26 $207.80

93531 26 $432.99

93532 26 $529.49

93533 26 $354.60

93561 26 $47.70

93562 26 $38.45

93563 $58.42

93564 $61.01

93565 $45.11

93566 $151.23

93567 $127.20

93568 $138.66

93571 26 $73.58

93572 26 $53.25

93580 $973.20

93581 $1,320.04

93582 $660.39

93583 $739.15

93590 $1,124.80

93591 $932.90

93592 $409.69

93600 26 $119.80

93602 26 $117.58

93603 26 $117.58

93609 26 $279.91

93610 26 $164.91

93612 26 $163.80

93613 $296.92

93615 26 $39.93

93616 26 $62.49

93618 26 $221.85

93619 26 $394.16

270 of 300


ND Medicaid


as of 7/1/2020



93620 26 $631.92

93621 26 $117.95

93622 26 $173.05

93623 26 $159.74

93624 26 $241.08

93631 26 $396.01

93640 26 $179.70

93641 26 $314.66

93642 $342.40

93642 26 $257.35

93642 TC $85.04

93644 $206.69

93644 26 $152.71

93644 TC $53.98

93650 $591.61

93653 $836.02

93654 $1,119.26

93655 $425.96

93656 $1,122.59

93657 $425.59

93660 $164.54

93660 26 $97.62

93660 TC $66.93

93662 26 $149.01

93668 $15.90

93701 $26.99

93702 $143.84

93724 $293.96

93724 26 $254.39

93724 TC $39.56

93750 $58.42

93784 $47.70

93786 $23.29

93788 $4.81

93790 $19.23

271 of 300


ND Medicaid


as of 7/1/2020



93793 $11.83

93797 $16.64

93798 $26.25

93880 $207.06

93880 26 $40.67

93880 TC $166.39

93882 $132.74

93882 26 $25.14

93882 TC $107.60

93886 $283.23

93886 26 $48.81

93886 TC $234.43

93888 $168.24

93888 26 $26.62

93888 TC $141.62

93890 $287.67

93890 26 $53.25

93890 TC $234.43

93892 $323.54

93892 26 $61.75

93892 TC $261.79

93893 $371.61

93893 26 $62.12

93893 TC $309.49

93922 $88.37

93922 26 $12.94

93922 TC $75.43

93923 $136.81

93923 26 $22.19

93923 TC $114.62

93924 $169.35

93924 26 $24.77

93924 TC $144.58

93925 $263.27

93925 26 $39.93

272 of 300


ND Medicaid


as of 7/1/2020



93925 TC $223.33

93926 $155.30

93926 26 $24.40

93926 TC $130.89

93930 $213.35

93930 26 $40.30

93930 TC $173.05

93931 $133.11

93931 26 $24.77

93931 TC $108.34

93970 $202.26

93970 26 $35.13

93970 TC $167.13

93971 $126.83

93971 26 $22.92

93971 TC $103.90

93975 $287.67

93975 26 $58.79

93975 TC $228.88

93976 $170.09

93976 26 $40.67

93976 TC $129.42

93978 $194.49

93978 26 $39.56

93978 TC $154.93

93979 $124.98

93979 26 $24.77

93979 TC $100.20

93980 $127.20

93980 26 $63.97

93980 TC $63.23

93981 $76.17

93981 26 $22.19

93981 TC $53.98

93985 $276.58

273 of 300


ND Medicaid


as of 7/1/2020



93985 26 $39.19

93985 TC $237.38

93986 $159.74

93986 26 $24.77

93986 TC $134.96

93990 $160.11

93990 26 $24.40

93990 TC $135.70

94002 $94.29

94003 $68.04

94004 $50.29

94010 $36.98

94010 26 $8.87

94010 TC $28.10

94011 $88.74

94012 $144.95

94013 $19.60

94014 $57.68

94015 $31.43

94016 $26.25

94060 $61.01

94060 26 $13.31

94060 TC $47.70

94070 $61.01

94070 26 $29.58

94070 TC $31.43

94200 $23.29

94200 26 $4.81

94200 TC $18.49

94250 $28.47

94250 26 $5.92

94250 TC $22.56

94375 $40.67

94375 26 $15.53

94375 TC $25.14

274 of 300


ND Medicaid


as of 7/1/2020



94400 $58.05

94400 26 $19.97

94400 TC $38.09

94450 $68.77

94450 26 $19.60

94450 TC $49.18

94452 $54.72

94452 26 $15.16

94452 TC $39.56

94453 $74.32

94453 26 $19.60

94453 TC $54.72

94610 $56.94

94617 $94.29

94617 26 $34.39

94617 TC $59.90

94618 $34.39

94618 26 $23.66

94618 TC $10.72

94621 $164.17

94621 26 $72.10

94621 TC $92.07

94640 $18.12

94644 $55.46

94645 $17.01

94660 $65.82

94662 $36.98

94664 $17.01

94667 $25.51

94668 $29.58

94669 $30.32

94680 $55.83

94680 26 $13.31

94680 TC $42.52

94681 $55.09

275 of 300


ND Medicaid


as of 7/1/2020



94681 26 $10.72

94681 TC $44.37

94690 $52.88

94690 26 $4.07

94690 TC $48.81

94726 $55.83

94726 26 $12.94

94726 TC $42.89

94727 $45.48

94727 26 $12.94

94727 TC $32.54

94728 $42.52

94728 26 $13.31

94728 TC $29.21

94729 $58.79

94729 26 $9.61

94729 TC $49.18

94750 $91.70

94750 26 $11.46

94750 TC $80.24

94760 $2.22

94761 $3.70

94762 $26.99

94770 $7.40

94780 $52.14

94781 $20.34

95004 $4.07

95012 $20.34

95017 $8.50

95018 $21.82

95024 $8.13

95027 $4.81

95028 $12.94

95044 $5.18

95052 $6.29

276 of 300


ND Medicaid


as of 7/1/2020



95056 $48.07

95060 $36.24

95065 $26.62

95070 $34.02

95071 $38.82

95076 $123.50

95079 $87.63

95115 $9.24

95117 $10.72

95144 $15.16

95145 $31.80

95146 $58.79

95147 $59.16

95148 $86.52

95149 $114.99

95165 $14.79

95170 $11.09

95180 $141.25

95249 $56.20

95250 $155.30

95251 $36.61

95717 $106.49

95718 $139.77

95719 $164.17

95720 $216.31

95721 $218.16

95722 $264.38

95723 $269.92

95724 $337.59

95725 $308.01

95726 $426.70

95782 $937.71

95782 26 $131.26

95782 TC $806.44

95783 $996.13

277 of 300


ND Medicaid


as of 7/1/2020



95783 26 $142.36

95783 TC $853.77

95803 $155.67

95803 26 $46.59

95803 TC $109.08

95805 $430.77

95805 26 $61.38

95805 TC $369.39

95807 $422.63

95807 26 $63.97

95807 TC $358.67

95808 $678.14

95808 26 $90.96

95808 TC $587.18

95810 $633.03

95810 26 $126.09

95810 TC $506.94

95811 $661.50

95811 26 $130.89

95811 TC $530.60

95812 $342.40

95812 26 $59.90

95812 TC $282.50

95813 $424.48

95813 26 $90.59

95813 TC $333.89

95816 $379.74

95816 26 $59.90

95816 TC $319.84

95819 $450.74

95819 26 $60.27

95819 TC $390.46

95822 $408.58

95822 26 $60.27

95822 TC $348.31

278 of 300


ND Medicaid


as of 7/1/2020



95824 26 $40.67

95829 $1,946.04

95829 26 $346.83

95829 TC $1,599.20

95830 $523.58

95836 $111.30

95851 $22.56

95852 $19.60

95857 $56.94

95860 $124.98

95860 26 $54.35

95860 TC $70.62

95861 $178.22

95861 26 $85.78

95861 TC $92.44

95863 $220.75

95863 26 $103.90

95863 TC $116.84

95864 $259.94

95864 26 $110.93

95864 TC $149.01

95865 $158.63

95865 26 $87.26

95865 TC $71.36

95866 $140.88

95866 26 $69.88

95866 TC $70.99

95867 $112.04

95867 26 $44.37

95867 TC $67.67

95868 $147.16

95868 26 $65.82

95868 TC $81.35

95869 $99.46

95869 26 $20.71

279 of 300


ND Medicaid


as of 7/1/2020



95869 TC $78.76

95870 $93.92

95870 26 $20.71

95870 TC $73.21

95872 $207.06

95872 26 $158.63

95872 TC $48.44

95873 $79.87

95873 26 $20.71

95873 TC $59.16

95874 $82.09

95874 26 $20.34

95874 TC $61.75

95875 $139.03

95875 26 $61.38

95875 TC $77.65

95885 $65.08

95885 26 $19.23

95885 TC $45.85

95886 $100.94

95886 26 $47.70

95886 TC $53.25

95887 $88.00

95887 26 $39.19

95887 TC $48.81

95905 $56.57

95905 26 $2.96

95905 TC $53.61

95907 $99.46

95907 26 $56.20

95907 TC $43.26

95908 $126.46

95908 26 $70.25

95908 TC $56.20

95909 $150.86

280 of 300


ND Medicaid


as of 7/1/2020



95909 26 $83.94

95909 TC $66.93

95910 $198.93

95910 26 $112.41

95910 TC $86.52

95911 $238.49

95911 26 $139.40

95911 TC $99.10

95912 $272.14

95912 26 $165.65

95912 TC $106.49

95913 $315.03

95913 26 $196.71

95913 TC $118.32

95921 $89.48

95921 26 $47.33

95921 TC $42.15

95922 $101.68

95922 26 $49.92

95922 TC $51.77

95923 $133.85

95923 26 $47.70

95923 TC $86.15

95924 $155.30

95924 26 $90.96

95924 TC $64.34

95925 $144.95

95925 26 $28.84

95925 TC $116.10

95926 $138.29

95926 26 $28.47

95926 TC $109.82

95927 $137.55

95927 26 $28.10

95927 TC $109.45

281 of 300


ND Medicaid


as of 7/1/2020



95928 $234.43

95928 26 $83.20

95928 TC $151.23

95929 $241.45

95929 26 $83.20

95929 TC $158.26

95930 $69.51

95930 26 $19.60

95930 TC $49.92

95933 $85.78

95933 26 $32.91

95933 TC $52.88

95937 $97.99

95937 26 $36.24

95937 TC $61.75

95938 $363.84

95938 26 $48.07

95938 TC $315.77

95939 $546.50

95939 26 $124.61

95939 TC $421.89

95940 $33.65

95954 $404.52

95954 26 $117.58

95954 TC $286.93

95955 $218.90

95955 26 $56.20

95955 TC $162.69

95957 $265.86

95957 26 $107.23

95957 TC $158.63

95958 $601.60

95958 26 $233.69

95958 TC $367.91

95961 $319.84

282 of 300


ND Medicaid


as of 7/1/2020



95961 26 $166.02

95961 TC $153.82

95962 $271.40

95962 26 $178.96

95962 TC $92.44

95965 26 $437.42

95966 26 $221.85

95967 26 $193.75

95970 $19.60

95971 $51.77

95972 $58.05

95976 $42.15

95977 $55.09

95980 $45.48

95981 $36.24

95982 $57.31

95983 $52.14

95984 $45.85

95990 $93.18

95991 $117.95

95992 $45.85

96000 $96.51

96001 $113.89

96002 $22.56

96003 $17.75

96004 $116.47

96020 26 $169.72

96040 $46.59

96105 $106.49

96110 $9.98

96112 $141.25

96113 $63.23

96116 $100.20

96121 $86.52

96125 $113.15

283 of 300


ND Medicaid


as of 7/1/2020



96127 $4.81

96130 $123.13

96131 $94.29

96132 $137.92

96133 $103.53

96136 $48.44

96137 $44.74

96138 $39.19

96139 $39.19

96146 $1.85

96156 $100.57

96158 $68.77

96159 $24.03

96160 $2.59

96161 $2.59

96164 $9.98

96165 $4.81

96167 $73.95

96168 $26.25

96170 $82.83

96171 $29.95

96360 $35.13

96361 $13.68

96365 $72.84

96366 $22.19

96367 $31.80

96368 $21.45

96369 $165.65

96370 $15.53

96371 $66.19

96372 $14.42

96373 $18.86

96374 $40.67

96375 $16.64

96377 $20.34

284 of 300


ND Medicaid


as of 7/1/2020



96401 $80.98

96402 $32.54

96405 $86.15

96406 $132.37

96409 $111.30

96411 $60.27

96413 $144.21

96415 $31.06

96416 $144.21

96417 $69.88

96420 $106.49

96422 $175.64

96423 $81.35

96425 $186.36

96440 $924.03

96446 $207.06

96450 $185.62

96521 $150.86

96522 $125.72

96523 $28.47

96542 $136.07

96567 $139.03

96570 $56.57

96571 $26.62

96573 $222.59

96574 $279.17

96900 $22.92

96904 $70.99

96910 $120.91

96912 $103.16

96913 $149.75

96920 $169.35

96921 $185.62

96922 $252.91

96931 $179.33

285 of 300


ND Medicaid


as of 7/1/2020



96932 $131.63

96933 $47.33

96934 $109.08

96935 $63.97

96936 $45.11

97022 $18.49

97032 $15.16

97035 $14.79

97110 $31.80

97112 $36.61

97113 $40.30

97116 $31.43

97129 $24.77

97130 $23.66

97140 $29.21

97150 $18.86

97151 $28.15

97152 $20.83

97153 $9.59

97154 $2.41

97155 $28.15

97161 $88.74

97162 $88.74

97163 $88.74

97164 $61.01

97165 $94.29

97166 $93.92

97167 $93.92

97168 $65.08

97530 $41.04

97537 $34.02

97542 $34.39

97597 $100.20

97598 $47.33

97605 $45.48

286 of 300


ND Medicaid


as of 7/1/2020



97606 $53.61

97607 $349.79

97608 $350.53

97761 $43.63

97802 $38.82

97803 $33.65

97804 $17.38

97810 $37.72

97811 $28.47

97813 $42.15

97814 $34.39

98925 $32.17

98926 $46.59

98927 $61.01

98928 $74.69

98929 $88.74

98940 $42.78

98941 $59.51

98942 $77.48

98966 $14.42

98967 $27.73

98968 $41.04

99151 $76.54

99152 $52.51

99153 $10.72

99155 $85.78

99156 $79.13

99157 $65.08

99170 $163.43

99173 $2.59

99174 $5.55

99175 $25.51

99177 $4.44

99183 $111.67

99184 $228.51

287 of 300


ND Medicaid


as of 7/1/2020



99188 $27.00

99195 $104.27

99201 $46.59

99202 $77.28

99203 $109.45

99204 $167.13

99205 $211.13

99211 $23.66

99212 $46.22

99213 $76.54

99214 $110.93

99215 $149.01

99217 $73.95

99218 $101.31

99219 $138.29

99220 $188.21

99221 $102.79

99222 $139.77

99223 $205.96

99224 $40.30

99225 $73.95

99226 $106.49

99231 $39.93

99232 $73.58

99233 $106.12

99234 $135.33

99235 $171.94

99236 $221.49

99238 $74.32

99239 $109.45

99281 $22.56

99282 $43.63

99283 $65.45

99284 $119.80

99285 $173.79

288 of 300


ND Medicaid


as of 7/1/2020



99291 $283.97

99292 $124.98

99304 $92.07

99305 $132.37

99306 $170.46

99307 $44.74

99308 $70.62

99309 $93.18

99310 $137.55

99315 $74.69

99316 $107.60

99318 $97.99

99324 $55.83

99325 $81.35

99326 $141.62

99327 $190.06

99328 $224.44

99334 $61.75

99335 $97.62

99336 $137.92

99337 $198.56

99341 $55.83

99342 $80.24

99343 $131.63

99344 $186.36

99345 $226.66

99347 $55.83

99348 $85.78

99349 $131.63

99350 $183.03

99354 $132.37

99355 $100.57

99356 $94.29

99357 $95.03

99360 $62.86

289 of 300


ND Medicaid


as of 7/1/2020



99375 $106.86

99378 $106.86

99381 $113.52

99382 $119.06

99383 $123.87

99384 $140.14

99385 $135.70

99386 $157.15

99387 $170.46

99391 $102.42

99392 $109.08

99393 $108.71

99394 $119.43

99395 $122.39

99396 $130.15

99397 $140.14

99406 $15.53

99407 $29.21

99408 $36.61

99409 $70.99

99421 $15.53

99422 $30.69

99423 $49.92

99458 $42.15

99460 $97.62

99461 $93.18

99462 $42.89

99463 $112.78

99464 $76.17

99465 $149.01

99466 $243.30

99467 $122.02

99468 $938.08

99469 $406.36

99471 $811.99

290 of 300


ND Medicaid


as of 7/1/2020



99472 $410.06

99473 $11.09

99474 $15.16

99475 $571.65

99476 $353.12

99477 $356.08

99478 $140.14

99479 $127.20

99480 $122.02

99483 $267.34

99487 $93.55

99489 $45.11

99490 $42.15

99491 $84.30

99495 $189.69

99496 $250.33

0373T $11.52

0509T $80.24

0509T 26 $22.56

0509T TC $57.68

G0027 $6.50

G0101 $40.30

G0102 $23.29

G0103 $19.31

G0104 $181.92

G0105 $340.18

G0106 $219.64

G0106 26 $54.72

G0106 TC $164.91

G0108 $57.31

G0109 $15.90

G0117 $57.31

G0118 $45.11

G0120 $220.75

G0120 26 $55.83

291 of 300


ND Medicaid


as of 7/1/2020



G0120 TC $164.91

G0121 $340.55

G0122 $322.80

G0122 26 $51.40

G0122 TC $271.40

G0123 $20.26

G0124 $26.62

G0127 $24.40

G0128 $7.40

G0130 $36.61

G0130 26 $11.83

G0130 TC $24.77

G0141 $26.62

G0143 $27.05

G0144 $43.97

G0145 $26.49

G0147 $15.12

G0148 $31.94

G0166 $106.12

G0168 $110.93

G0179 $41.78

G0180 $54.35

G0181 $109.45

G0182 $110.19

G0237 $9.24

G0238 $9.61

G0239 $12.20

G0245 $68.04

G0246 $39.93

G0247 $82.83

G0248 $60.27

G0249 $60.27

G0250 $9.24

G0252 26 $78.39

G0268 $51.03

292 of 300


ND Medicaid


as of 7/1/2020



G0270 $33.65

G0271 $17.38

G0277 $141.25

G0278 $13.68

G0279 $56.57

G0279 26 $30.69

G0279 TC $25.88

G0281 $14.05

G0288 $34.76

G0289 $87.26

G0296 $29.58

G0297 $247.00

G0297 26 $52.88

G0297 TC $194.12

G0306 $7.77

G0307 $6.47

G0328 $18.05

G0329 $11.46

G0337 $74.69

G0341 $2,199.32

G0342 $705.50

G0343 $1,164.00

G0372 $9.24

G0396 $36.61

G0397 $68.41

G0403 $17.38

G0404 $8.50

G0405 $8.50

G0406 $39.56

G0407 $73.58

G0408 $105.75

G0409 $13.31

G0412 $737.30

G0413 $1,077.11

G0414 $1,017.94

293 of 300


ND Medicaid


as of 7/1/2020



G0415 $1,385.48

G0416 $354.60

G0416 26 $188.95

G0416 TC $165.65

G0422 $110.93

G0423 $110.93

G0425 $101.68

G0426 $138.66

G0427 $205.22

G0429 $99.83

G0432 $19.57

G0433 $18.29

G0435 $11.98

G0438 $174.53

G0439 $118.32

G0455 $131.63

G0471 $5.00

G0472 $46.35

G0475 $24.08

G0476 $35.09

G0480 $114.43

G0481 $156.59

G0482 $198.74

G0483 $246.92

G0499 $28.27

G0500 $58.79

G0659 $62.14

G2023 $23.46

G2024 $25.46

G2058 $38.09

G2061 $12.20

G2062 $21.82

G2063 $34.02

G2064 $92.07

G2065 $39.56

294 of 300


ND Medicaid


as of 7/1/2020



G2067 $207.49

G2068 $258.47

G2069 $1,757.29

G2070 $5,326.84

G2071 $427.32

G2072 $5,545.95

G2073 $1,342.67

G2074 $161.71

G2076 $179.49

G2077 $110.28

G2078 $35.28

G2079 $86.26

G2080 $30.94

G2082 $777.23

G2083 $1,136.27

G2086 $418.20

G2086 $404.36

G2087 $372.72

G2087 $359.89

G2088 $70.99

G2088 $69.01

G6001 $121.65

G6001 26 $33.28

G6001 TC $88.37

G6002 $78.39

G6002 26 $21.45

G6002 TC $56.94

G6003 $194.12

G6004 $146.79

G6005 $146.79

G6006 $146.79

G6007 $275.84

G6008 $202.63

G6009 $201.15

G6010 $201.15

295 of 300


ND Medicaid


as of 7/1/2020



G6011 $272.51

G6012 $268.81

G6013 $269.18

G6014 $269.18

G6015 $377.89

G6016 $377.15

G9143 $120.72

H1000 $86.19

H1001 $57.46

H1002 $57.46

H1003 $57.46

H1004 $57.46

P3000 $15.12

P3001 $26.62

P9603 $0.33

P9604 $4.79

Q0035 $19.60

Q0035 26 $8.87

Q0035 TC $10.72

Q0091 $44.00

Q0092 $24.03

Q0111 $15.12

Q0138 $1.04

Q0139 $1.04

Q0162 $0.02

Q0166 $0.69

Q0510 $61.79

Q0511 $29.66

Q0512 $19.77

Q0513 $40.78

Q0514 $81.55

Q2043 $45,942.63

Q2050 $295.52

Q3014 $31.95

Q3027 $53.56

296 of 300


ND Medicaid


as of 7/1/2020



Q4001 $52.76

Q4002 $199.37

Q4003 $37.91

Q4004 $131.16

Q4005 $13.97

Q4006 $31.48

Q4007 $6.98

Q4008 $15.73

Q4009 $9.32

Q4010 $21.00

Q4011 $4.66

Q4012 $10.48

Q4013 $16.95

Q4014 $28.64

Q4015 $8.48

Q4016 $14.32

Q4017 $9.83

Q4018 $15.67

Q4019 $4.89

Q4020 $7.84

Q4021 $7.25

Q4022 $13.13

Q4023 $3.66

Q4024 $6.52

Q4025 $40.75

Q4026 $127.19

Q4027 $20.38

Q4028 $63.58

Q4029 $31.16

Q4030 $81.99

Q4031 $15.57

Q4032 $41.00

Q4033 $29.07

Q4034 $72.26

Q4035 $14.54

297 of 300


ND Medicaid


as of 7/1/2020



Q4036 $36.14

Q4037 $17.72

Q4038 $44.40

Q4039 $8.88

Q4040 $22.22

Q4041 $21.56

Q4042 $36.78

Q4043 $10.76

Q4044 $18.41

Q4045 $12.51

Q4046 $20.10

Q4047 $6.23

Q4048 $10.08

Q4049 $2.30

Q4074 $139.83

Q4081 $1.06

Q4101 $30.55

Q4102 $11.34

Q4106 $32.51

Q4132 $115.54

Q4133 $140.99

Q4160 $101.25

Q4186 $163.35

Q4195 $119.99

Q4196 $113.86

Q5101 $0.55

Q9956 $32.13

Q9956 $32.13

Q9958 $0.08

Q9958 $0.08

Q9960 $0.17

R0070 $73.43

R0075 $73.43

S0302 $130.70

S0390 $20.79

298 of 300


ND Medicaid


as of 7/1/2020



S2083 $106.81

S5497 $7.20

S9326 $55.93

S9327 $71.90

S9330 $55.93

S9331 $71.90

S9338 $71.90

S9339 $55.93

S9364 $263.57

S9373 $71.90

S9497 $96.19

S9500 $72.14

S9501 $79.46

S9502 $79.46

S9503 $79.46

S9504 $96.19

T1001 $16.40

T1002 $17.14

T1003 $13.96

T1004 $10.74

T1015 $114.34

T1021 $18.21

T1025 $345.07

T1030 $68.54

T1031 $55.83

V2020 $25.55

V2025 $15.99

V2104 $7.20

V2105 $4.79

V2111 $2.81

V2204 $16.80

V2299 $17.57

V2304 $22.85

V2430 $35.16

V2710 $74.27

299 of 300


ND Medicaid


as of 7/1/2020



V2715 $3.19

V2718 $12.41

V2744 $7.45

V2745 $2.00

V2760 $2.81

V2780 $2.40

V2784 $7.98

300 of 300

nd medicaid professional services fee schedule as of 7/1/2020 · 15756 $2,331.69 15757 $2,319.86...

Documents